ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. What are the nursing interventions for a patient with pneumonia?
- A. Providing fluids and rest
- B. Monitoring lung sounds and respiratory rate
- C. Encouraging coughing and deep breathing exercises
- D. Administering antibiotics and providing oxygen therapy
Correct answer: B
Rationale: The correct nursing interventions for a patient with pneumonia include monitoring lung sounds and respiratory rate to assess the effectiveness of treatment and the patient's respiratory status. Providing fluids and rest (Choice A) can be supportive measures but are not specific nursing interventions for pneumonia. Encouraging coughing and deep breathing exercises (Choice C) can be helpful for airway clearance but may not be appropriate for all patients with pneumonia. Administering antibiotics and providing oxygen therapy (Choice D) are medical interventions rather than nursing interventions.
2. A client with a history of falls is under the care of a nurse. Which intervention is most important to implement?
- A. Increase the frequency of bed checks.
- B. Use bed alarms to prevent falls.
- C. Keep the room well lit during the day.
- D. Encourage the client to use a walker for mobility.
Correct answer: B
Rationale: Using bed alarms to prevent falls is the most important intervention to implement for a client with a history of falls. Bed alarms can provide timely alerts to the healthcare team, allowing for quick assistance to prevent falls. Increasing the frequency of bed checks may not necessarily prevent falls as effectively as direct intervention with bed alarms. Keeping the room well lit is important for general safety but may not address the immediate risk of falls. Encouraging the client to use a walker for mobility is beneficial but may not be as crucial as implementing bed alarms to prevent falls in this scenario.
3. A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?
- A. Increase dietary intake of raw vegetables
- B. Limit activity
- C. Drink four to five glasses of water daily
- D. Bear down hard when defecating
Correct answer: C
Rationale: The correct instruction the nurse should include is to advise the client to drink four to five glasses of water daily. Increasing water intake helps alleviate constipation by softening stool and increasing bowel movements. Choice A, increasing dietary intake of raw vegetables, can be helpful in preventing constipation but may not be sufficient as the sole intervention for someone already experiencing constipation. Choice B, limiting activity, can worsen constipation as physical activity helps stimulate bowel movements. Choice D, bearing down hard when defecating, can lead to other issues like hemorrhoids and should be avoided.
4. A patient with a history of asthma is admitted with shortness of breath. What is the nurse's priority intervention?
- A. Administer a bronchodilator as prescribed.
- B. Encourage the patient to use an incentive spirometer.
- C. Place the patient in a high Fowler's position.
- D. Monitor the patient's oxygen saturation closely.
Correct answer: A
Rationale: The correct answer is to administer a bronchodilator as prescribed. This intervention is the priority for a patient with asthma experiencing shortness of breath as it helps relax the airways, making breathing easier. Encouraging the use of an incentive spirometer (Choice B) is beneficial for lung expansion but not the priority in this acute situation. Placing the patient in a high Fowler's position (Choice C) can also help with breathing but is not as immediate as administering a bronchodilator. While monitoring the patient's oxygen saturation closely (Choice D) is important, the immediate action to address the breathing difficulty is administering a bronchodilator.
5. Which of the following best describes a somatic symptom disorder?
- A. Client experiences sudden onset of symptoms due to stress
- B. Physical manifestations occur due to underlying medical conditions
- C. Client has excessive preoccupation with physical symptoms without a medical cause
- D. Client avoids medical care due to fear of receiving a diagnosis
Correct answer: C
Rationale: The correct answer is C. Somatic symptom disorder is characterized by individuals having excessive preoccupation with physical symptoms that may or may not have an identifiable medical cause. Choice A is incorrect because the sudden onset of symptoms due to stress is more indicative of acute stress reaction. Choice B is incorrect as it describes physical manifestations related to known medical conditions, not somatic symptom disorder. Choice D is incorrect as it relates to health anxiety or illness anxiety disorder, where individuals avoid seeking medical care due to fear of receiving a diagnosis.
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