ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. What is the priority action for a patient with a fever?
- A. Administer an antipyretic medication as prescribed.
- B. Assess the patient's temperature regularly.
- C. Provide cooling measures such as a cool compress.
- D. Provide the patient with blankets for comfort.
Correct answer: B
Rationale: The priority action when a patient has a fever is to assess the patient's temperature regularly. Monitoring the temperature helps track the effectiveness of interventions and detect any worsening fever. Administering antipyretic medication (Choice A) should be done based on healthcare provider's orders after assessing the patient's condition. While providing cooling measures such as a cool compress (Choice C) can help reduce fever, assessing the temperature takes precedence. Providing blankets for comfort (Choice D) is not the priority when dealing with a fever.
2. Which of the following clients requiring crutches should a nurse teach about how to use a three-point gait?
- A. A client who has a right femur fracture with no weight-bearing on the affected leg
- B. A client who has bilateral leg braces due to paralysis of the lower extremities
- C. A client who has bilateral knee replacements with partial weight-bearing on both legs
- D. A client who is able to bear full weight on both lower extremities
Correct answer: A
Rationale: A three-point gait is recommended for clients who are non-weight bearing on one leg. In this case, a client with a right femur fracture requiring no weight-bearing on the affected leg would benefit from learning how to use a three-point gait. Choices B, C, and D are incorrect because they involve clients who have varying degrees of weight-bearing ability on both legs, which would not require the use of a three-point gait.
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. A patient is receiving an opioid analgesic for pain management. What is the most important assessment for the nurse to perform?
- A. Monitor the patient's blood pressure.
- B. Assess the patient's respiratory rate.
- C. Monitor the patient's oxygen saturation.
- D. Assess the patient's heart rate.
Correct answer: B
Rationale: The correct answer is to assess the patient's respiratory rate. When a patient is receiving opioids, it is crucial to monitor their respiratory rate as opioids can depress the respiratory system, leading to respiratory depression and potential respiratory failure. Monitoring blood pressure, oxygen saturation, and heart rate are important assessments as well, but the priority lies in assessing respiratory rate due to the risk of respiratory depression associated with opioid use.
5. A patient is prescribed a diuretic for hypertension. What is the most important assessment the nurse should perform?
- A. Monitor the patient's respiratory rate.
- B. Check the patient's blood pressure regularly.
- C. Monitor the patient's potassium levels.
- D. Monitor the patient's sodium levels.
Correct answer: D
Rationale: Corrected Rationale: When a patient is prescribed a diuretic for hypertension, monitoring the patient's sodium levels is crucial. Diuretics can lead to alterations in sodium levels, potentially causing complications like hyponatremia. While monitoring other parameters like respiratory rate, blood pressure, and potassium levels may also be important, the primary concern with diuretic therapy is the risk of sodium imbalance, making the monitoring of sodium levels the most critical assessment.
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