ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. What are the key nursing interventions for a patient experiencing acute respiratory distress syndrome (ARDS)?
- A. Positioning the patient in a prone position
- B. Monitoring vital signs and lung sounds
- C. Preparing for mechanical ventilation
- D. Administering supplemental oxygen
Correct answer: A
Rationale: The correct answer is A: Positioning the patient in a prone position. Prone positioning is a key nursing intervention for patients with acute respiratory distress syndrome (ARDS) as it helps improve oxygenation by allowing better lung ventilation. Choice B, monitoring vital signs and lung sounds, is important but not a key intervention specific to ARDS. Choice C, preparing for mechanical ventilation, may be necessary in severe cases of ARDS but is not a primary nursing intervention. Choice D, administering supplemental oxygen, is a common supportive measure but is not specific to ARDS interventions.
2. A nurse on a rehabilitation unit is creating a plan of care for a newly admitted client who has difficulty swallowing following a stroke. Which of the following inter-professional team members should the nurse anticipate consulting regarding the client's condition?
- A. Speech-language pathologist
- B. Occupational therapist
- C. Dietitian
- D. Pharmacy technician
Correct answer: A
Rationale: The correct answer is A, Speech-language pathologist. A speech-language pathologist specializes in evaluating and treating swallowing difficulties, known as dysphagia, which commonly occurs following a stroke. They are experts in developing strategies to help individuals improve their ability to swallow safely. Occupational therapists (B) focus on helping individuals regain independence in activities of daily living, not specifically addressing swallowing concerns. Dietitians (C) primarily work on developing appropriate nutrition plans but may not directly address swallowing issues. Pharmacy technicians (D) assist pharmacists in dispensing medications and are not directly involved in managing swallowing difficulties.
3. The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?
- A. Brachial pulse in the right arm
- B. Radial pulse in the right arm
- C. Brachial pulse in the left arm
- D. Radial pulse in the left arm
Correct answer: D
Rationale: The correct answer is to palpate the radial pulse in the left arm. When the antecubital insertion site is on the left side, it is important to assess the radial pulse on the same side to monitor circulation accurately. Palpating the brachial pulse in the right or left arm or the radial pulse in the right arm would not provide direct information about the circulation related to the catheterization site.
4. The nurse is evaluating the effectiveness of guided imagery for pain management in a patient with second- and third-degree burns requiring extensive dressing changes. Which finding best indicates the effectiveness of guided imagery?
- A. The patient's need for analgesic medication decreases during the dressing changes.
- B. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10.
- C. The patient asks for pain medication during the dressing changes only once throughout the procedure.
- D. The patient's facial expressions remain stoic during the procedure.
Correct answer: A
Rationale: The correct answer is A. A reduction in the need for analgesic medication indicates that guided imagery is effective in managing the patient's pain. Choices B, C, and D do not directly measure the effectiveness of guided imagery. A patient rating pain as 6 on a scale of 0 to 10, asking for pain medication once, or having stoic facial expressions may not necessarily reflect the impact of guided imagery on pain management.
5. The nurse notes that a healthcare provider has prescribed a higher than normal dose of medication. What action should the nurse take?
- A. Administer the prescribed dose
- B. Ask another nurse to verify the dose
- C. Administer half of the dose
- D. Contact the healthcare provider to clarify the prescription
Correct answer: D
Rationale: When a healthcare provider prescribes a dose that is higher than normal, it is crucial for the nurse to contact the provider to clarify the prescription. Administering the prescribed dose without clarification can lead to potential harm to the patient due to the elevated dosage. Asking another nurse to verify the dose may not provide the necessary clarification from the prescriber. Administering only half of the prescribed dose without consulting the healthcare provider is not the appropriate action, as the full rationale behind the higher dose needs to be understood before any administration.
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