ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. What are the nursing interventions for a patient with acute kidney injury (AKI)?
- A. Preparing the patient for dialysis if necessary
- B. Providing dietary modifications to reduce potassium
- C. Monitoring urine output and electrolytes
- D. Administering fluids and monitoring blood pressure
Correct answer: A
Rationale: The correct nursing intervention for a patient with acute kidney injury (AKI) includes preparing the patient for dialysis if necessary. While choices B, C, and D are also important aspects of managing AKI, the critical intervention in severe cases is to prepare the patient for dialysis to support kidney function. Providing dietary modifications to reduce potassium, monitoring urine output and electrolytes, and administering fluids are essential components of the overall care plan for AKI patients, but in cases where the condition is severe or if conservative management fails, dialysis may be required to support the patient's kidney function and prevent further complications.
2. A client who is 97 years old has successfully been treated for heart failure and is found not breathing. There is no DNR order in place. What should the nurse do?
- A. Notify the family and await further instructions.
- B. Initiate CPR and call for emergency assistance.
- C. Allow the family to make decisions about care.
- D. Follow the family's wishes and perform no interventions.
Correct answer: B
Rationale: In this scenario, with no DNR order in place and the client not breathing, the nurse should initiate CPR and call for emergency assistance. Option A is incorrect as immediate action is required in the absence of breathing. Option C is incorrect as the nurse should act promptly to provide life-saving measures. Option D is incorrect because the nurse's primary duty is to provide care in the absence of a directive preventing intervention.
3. What should be done to ensure safety during the transfer of a patient with limited mobility?
- A. Have the patient use a gait belt for support.
- B. Encourage the patient to hold onto a walker.
- C. Lock the wheels on the bed and wheelchair.
- D. Ask the patient to transfer independently.
Correct answer: C
Rationale: The correct answer is to lock the wheels on the bed and wheelchair. This action helps prevent accidents by stabilizing the equipment during the transfer process. Having the patient use a gait belt for support (choice A) can be helpful but is not directly related to equipment safety. Encouraging the patient to hold onto a walker (choice B) is beneficial for ambulation but does not address the safety of equipment. Asking the patient to transfer independently (choice D) can pose risks, especially for a patient with limited mobility, and may not ensure safety during the transfer.
4. When a patient refuses to remove their religious jewelry before surgery, what is the best response for the nurse preparing for the procedure?
- A. Proceed with the surgery and document the refusal.
- B. Ask the patient for permission to secure the jewelry safely.
- C. Tape the jewelry to the patient's body during surgery.
- D. Tell the patient they must remove the jewelry for safety reasons.
Correct answer: B
Rationale: The best response for the nurse is to ask the patient for permission to secure the jewelry safely. Hospital policy typically requires jewelry to be secured or removed to prevent interference during surgery. Proceeding with the surgery without addressing the issue or taping the jewelry to the patient's body are not safe practices and can lead to complications during the procedure. Directing the patient to remove the jewelry without exploring alternative solutions is not patient-centered care and may create unnecessary tension.
5. A patient with a urinary tract infection (UTI) requires treatment. What is the most appropriate intervention?
- A. Encourage the patient to increase fluid intake.
- B. Administer antibiotics as prescribed.
- C. Recommend the patient take over-the-counter pain relievers.
- D. Encourage the patient to limit physical activity.
Correct answer: B
Rationale: The correct answer is to administer antibiotics as prescribed. Antibiotics are the primary treatment for urinary tract infections as they help eliminate the bacteria causing the infection. Encouraging the patient to increase fluid intake (Choice A) is a supportive measure to help flush out the bacteria but doesn't directly treat the infection. Over-the-counter pain relievers (Choice C) may help with discomfort but do not address the underlying infection. Limiting physical activity (Choice D) may be recommended for some conditions but is not the primary intervention for treating a UTI.
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