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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 nurse is planning care for a client who has dehydration and is receiving a continuous IV infusion of 0.9% sodium chloride. Which of the following interventions should the nurse include in the plan of care?
- A. Monitor the client's intake and output every 6 hours
- B. Administer furosemide to the client
- C. Check the client's IV infusion every 8 hours
- D. Offer the client 240 ml (8 oz) of oral fluids every 4 hours
Correct answer: D
Rationale: Offering the client 240 ml (8 oz) of oral fluids every 4 hours is essential to maintain hydration in a client with dehydration who is receiving continuous IV infusion. This intervention helps ensure an adequate fluid balance. Monitoring the client's intake and output every 6 hours is necessary to assess hydration status and response to treatment. Administering furosemide to the client, choice B, is contraindicated in dehydration as it can further deplete fluid volume. Checking the IV infusion every 8 hours, as in choice C, is important but not as critical as ensuring oral fluid intake to promote hydration.
3. A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider?
- A. Amphotericin B
- B. Amoxicillin-clavulanate
- C. Erythromycin
- D. Gentamicin
Correct answer: B
Rationale: Amoxicillin-clavulanate is related to penicillin, and a cross-sensitivity could occur, so the provider should be consulted.
4. Which action by a nurse demonstrates effective communication with a patient?
- A. Providing the patient with written information about their care.
- B. Maintaining eye contact and listening actively to the patient.
- C. Using medical jargon to explain the patient's condition.
- D. Speaking with the patient in a hurried manner to save time.
Correct answer: B
Rationale: Maintaining eye contact and actively listening to the patient is crucial in effective communication as it helps build rapport, shows empathy, and ensures that the patient feels heard and understood. Providing written information can be helpful, but the direct interaction is essential for effective communication. Using medical jargon may confuse the patient instead of clarifying their condition. Speaking hurriedly can make the patient feel rushed and not valued, hindering effective communication.
5. A nurse is evaluating a client receiving hemodialysis. Which of the following lab values requires immediate intervention?
- A. Sodium 135 mEq/L
- B. Potassium 6.5 mEq/L
- C. Calcium 9 mg/dL
- D. Chloride 98 mEq/L
Correct answer: B
Rationale: The correct answer is B. Potassium levels above 5.0 mEq/L can lead to cardiac issues, and a level of 6.5 mEq/L requires immediate intervention. Hyperkalemia can cause life-threatening cardiac arrhythmias. Choices A, C, and D are within normal ranges and do not require immediate intervention in the context of hemodialysis monitoring.
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