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 nurse is providing teaching to a client who has schizophrenia about thioridazine. Which of the following instructions should the nurse include?
- A. Report any sign of infection to the provider immediately
- B. Expect your blood pressure to increase
- C. Easy bruising may occur while taking this medication
- D. Muscle rigidity is an expected adverse effect during the first few days of therapy
Correct answer: A
Rationale: The correct answer is A: 'Report any sign of infection to the provider immediately.' This instruction is essential for clients taking thioridazine or other antipsychotic medications. Thioridazine does not typically affect blood pressure or cause easy bruising. Muscle rigidity is more commonly associated with other antipsychotic medications. Reporting signs of infection promptly is crucial as antipsychotic medications can affect the immune system, making individuals more susceptible to infections. Early detection and treatment of infections help prevent complications and ensure proper medication management.
3. A nurse is talking with a client who is about to start using transcutaneous electrical nerve stimulation (TENS) to manage chronic pain. Which of the following statements should the nurse identify as an indication that the client needs further teaching?
- A. I wish I didn't have to attach the electrodes to my skin
- B. I will need to shave the hair off the skin where I place the electrodes
- C. I hope I don't have to take as many pain pills
- D. It's unfortunate that I have to be in the hospital for this treatment
Correct answer: D
Rationale: TENS is a portable treatment that can be done at home, so the client should not expect to remain in the hospital for this treatment.
4. A client has bilateral eye patches following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?
- A. Explain to the client that their tray is here and place their hands on it
- B. Ask the client if they would prefer a liquid diet
- C. Assign an assistive personnel to feed the client
- D. Describe to the client the location of the food on the tray
Correct answer: D
Rationale: Describing the location of food on the tray helps promote independence for the client with bilateral eye patches. By providing clear instructions on where the food is placed, the client can independently locate and consume their meal. Option A is incorrect as physically placing the client's hands on the tray does not encourage independence. Option B is unnecessary unless there are specific dietary restrictions indicated. Option C does not promote the client's independence and should be avoided unless absolutely necessary.
5. A nurse is teaching a client about levothyroxine for primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?
- A. Take this medication until your symptoms are gone and then discontinue
- B. Symptoms improve immediately after starting the medication
- C. The medication decreases the overproduction of the thyroid hormone thyroxine
- D. Tremors, nervousness, and insomnia may indicate your dose is too high
Correct answer: D
Rationale: Tremors, nervousness, and insomnia indicate that the dose may be too high, requiring a dose adjustment.
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