ATI RN
ATI Capstone Comprehensive Assessment B
1. What is the most important nursing intervention for a patient with diarrhea?
- A. Encourage the patient to increase fluid intake.
- B. Monitor the patient's skin integrity.
- C. Check the patient's electrolyte levels.
- D. Educate the patient about infection control measures.
Correct answer: B
Rationale: The correct answer is to monitor the patient's skin integrity. This is crucial because diarrhea can lead to skin breakdown due to frequent bowel movements and increased moisture in the perineal area. By monitoring skin integrity, nurses can prevent skin breakdown, infection, and other associated issues. Encouraging fluid intake (Choice A) is important but not the most critical intervention. Checking electrolyte levels (Choice C) is essential but may not be the top priority at the onset. Educating the patient about infection control (Choice D) is important but secondary to preventing skin breakdown in a patient with diarrhea.
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. While working the night shift, a nurse observes a colleague behaving strangely. What is the best course of action?
- A. Ignore the behavior and continue working
- B. Report the behavior to the supervisor
- C. Ask the colleague if everything is okay
- D. Discuss the behavior with other colleagues
Correct answer: B
Rationale: When a nurse observes a colleague behaving strangely, the best course of action is to report the behavior to the supervisor. Unusual behavior by a healthcare professional could compromise patient safety and should be addressed promptly. Ignoring the behavior (Choice A) could potentially lead to negative outcomes for patients. Asking the colleague directly (Choice C) may not be appropriate if the behavior poses a risk. Discussing the behavior with other colleagues (Choice D) may not directly address the issue and could lead to gossip rather than a resolution.
4. What is the most appropriate action for a healthcare professional to take when a medication error occurs?
- A. Document the error in the patient's medical record.
- B. Report the error to the healthcare provider immediately.
- C. Apologize to the patient and explain what happened.
- D. Continue administering the medication and monitor the patient closely.
Correct answer: B
Rationale: When a medication error occurs, the most appropriate action for a healthcare professional is to report the error to the healthcare provider immediately. This is crucial for ensuring prompt corrective action to mitigate any potential harm to the patient. Documenting the error is important but should come after reporting it to the relevant authorities. Apologizing to the patient is important for maintaining trust and communication but should not take precedence over reporting and addressing the error. Continuing to administer the medication without addressing the error is unsafe and goes against patient safety protocols.
5. A healthcare provider writes a medication order that seems excessively high for the patient's condition. What is the nurse's first step?
- A. Administer the medication immediately.
- B. Hold the medication and consult the provider.
- C. Reduce the dose without consulting the provider.
- D. Administer the medication after double-checking with another nurse.
Correct answer: B
Rationale: The correct first step for the nurse when encountering a medication order that appears excessively high for the patient's condition is to hold the medication and consult the provider. Administering the medication immediately (Choice A) without clarification could pose a risk to the patient's safety. Reducing the dose without consulting the provider (Choice C) is not recommended as it may lead to suboptimal treatment. Administering the medication after double-checking with another nurse (Choice D) is not sufficient; consulting the provider directly is crucial to ensure the accuracy and safety of the medication order.
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