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 nurse is assessing a client who is postoperative. Which of the following findings should the nurse prioritize?
- A. Elevated temperature
- B. Low blood pressure
- C. Decreased urine output
- D. Increased heart rate
Correct answer: C
Rationale: In a postoperative client, decreased urine output is a crucial finding as it can indicate impaired kidney function or inadequate fluid balance. Prioritizing assessment and intervention for decreased urine output is essential to prevent complications like acute kidney injury. Elevated temperature, low blood pressure, and increased heart rate are also important, but they may not be as urgent or directly related to kidney function in a postoperative client.
3. A healthcare professional is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The healthcare professional should identify which of the following findings as an adverse effect of the medication?
- A. Drowsy but responsive when her name is called
- B. SaO2 94%
- C. Respiratory rate 8/min
- D. Pain level of 6 on a scale from 0 to 10
Correct answer: C
Rationale: A respiratory rate of 8/min is a significant adverse effect of morphine that indicates respiratory depression, which requires immediate intervention to prevent further complications. The client may not be effectively ventilating, leading to hypoxia and respiratory acidosis. Option A is less concerning as being drowsy but responsive is a common side effect of morphine. Option B indicates decreased oxygen saturation, which is also a concern but not as severe as respiratory depression. Option D is important but not as critical as the potential respiratory compromise indicated by the low respiratory rate.
4. A healthcare provider is assessing a patient with chronic pain. Which finding is most concerning?
- A. The patient reports a pain level of 6 on a scale of 0 to 10.
- B. The patient is lying still and refuses to move.
- C. The patient's pain persists despite medication.
- D. The patient reports feeling anxious and restless.
Correct answer: C
Rationale: In the context of chronic pain management, the most concerning finding is when the patient's pain persists despite medication. This suggests inadequate pain control or the need for a re-evaluation of the treatment plan. Choices A, B, and D are not as concerning in this scenario. A pain level of 6 on a scale of 0 to 10 is moderate and may be manageable with appropriate interventions. Patients with chronic pain can sometimes lie still due to pain or other reasons, and anxiety and restlessness are common in individuals with pain conditions but may not necessarily indicate a critical issue like uncontrolled pain.
5. Which question is essential during screening for alcohol use disorder?
- A. What is your current employment status?
- B. Have you experienced any blackouts or loss of consciousness?
- C. Have you been sleeping well over the past month?
- D. Do you have a family history of substance use?
Correct answer: B
Rationale: The essential question during screening for alcohol use disorder is asking about blackouts or loss of consciousness, which can be indicative of excessive drinking and related to alcohol use disorder. Choices A, C, and D are not as directly related to screening for alcohol use disorder. Employment status (Choice A) is not a primary question in alcohol use disorder screening. Sleep quality (Choice C) and family history of substance use (Choice D) may be relevant but are not as crucial as inquiring about blackouts or loss of consciousness.
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