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. A client with a history of seizures is admitted for monitoring. What should the nurse prioritize?
- A. Ensure the client is on seizure precautions.
- B. Educate the client about seizure triggers.
- C. Monitor for signs of an impending seizure.
- D. Initiate IV access for anti-seizure medication.
Correct answer: A
Rationale: The correct answer is to ensure the client is on seizure precautions. This is crucial in preventing injury during a seizure episode. While educating the client about seizure triggers (choice B) is important for long-term management, it is not the priority when the client is admitted for monitoring. Monitoring for signs of an impending seizure (choice C) is essential but does not address immediate safety concerns. Initiating IV access for anti-seizure medication (choice D) is not the priority unless a seizure occurs and medical intervention is needed.
3. A nurse is evaluating care of an immobilized patient. Which action will the nurse take?
- A. Involve primarily the patient's family and healthcare team to determine goal achievement.
- B. Focus on whether the interdisciplinary team is satisfied with the care.
- C. Use objective data solely to determine whether interventions have been successful.
- D. Compare the patient's actual outcomes with the outcomes in the care plan.
Correct answer: D
Rationale: The correct answer is D because comparing the patient's actual outcomes with the outcomes in the care plan is essential in evaluating the effectiveness of care provided to an immobilized patient. This comparison helps in identifying any disparities between the planned care and the actual care received, allowing the nurse to make necessary adjustments to improve patient outcomes. Choices A, B, and C are incorrect because while involving the patient's family and healthcare team, ensuring interdisciplinary team satisfaction, and using objective data are important aspects of patient care, they do not directly address the specific action needed to evaluate care for an immobilized patient.
4. A nurse observes a colleague not using proper hand hygiene. What should the nurse do first?
- A. Ignore the behavior and continue with care
- B. Discuss the behavior with other colleagues
- C. Confront the colleague about the behavior
- D. Report the behavior to the supervisor
Correct answer: D
Rationale: The correct action for the nurse to take first is to report the behavior to the supervisor. Proper hand hygiene is essential in preventing the spread of infections in healthcare settings. By reporting the observed behavior to the supervisor, the nurse is prioritizing patient safety and promoting a culture of accountability. Ignoring the behavior (Choice A) can put patients at risk, discussing it with other colleagues (Choice B) may not address the issue effectively, and confronting the colleague directly (Choice C) might not be the most appropriate initial step and could lead to conflicts rather than a constructive resolution.
5. A nurse is teaching a client who has a new prescription for amoxicillin clavulanate to treat pharyngitis. Which statement indicates understanding?
- A. I will double my dose if I miss one
- B. I should take this medication on an empty stomach between meals
- C. I will take the medication until my sore throat goes away
- D. I will stop taking this medication if I develop itching
Correct answer: C
Rationale: The client should never double the dose if a dose is missed. This can lead to an overdose, which can cause serious adverse effects. Instead, the client should take the next dose as scheduled or consult the provider for guidance.
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