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. What is the priority action when a patient is experiencing an allergic reaction to a medication?
- A. Monitor the patient's blood pressure every 15 minutes.
- B. Discontinue the medication and notify the healthcare provider.
- C. Administer an antihistamine to reduce symptoms.
- D. Monitor the patient's urine output closely.
Correct answer: B
Rationale: The correct answer is to discontinue the medication and notify the healthcare provider when a patient is experiencing an allergic reaction to a medication. This action is crucial to prevent further harm to the patient. Monitoring blood pressure (choice A) or urine output (choice D) may be important but is not the priority when managing an allergic reaction. Administering an antihistamine (choice C) should only be done after discontinuing the medication and consulting with the healthcare provider.
3. A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next?
- A. Check for orthostatic hypotension
- B. Use a gait belt
- C. Position the chair on the strong side
- D. Ask for assistance
Correct answer: A
Rationale: The correct next action for the nurse to take is to check for orthostatic hypotension. This step is crucial as it ensures the client's safety during the transfer process. Orthostatic hypotension is a drop in blood pressure that can occur when a person moves from a lying down position to a sitting or standing position. By checking for orthostatic hypotension before transferring the client, the nurse can prevent potential complications such as dizziness, lightheadedness, or falls. Choices B, C, and D are incorrect in this scenario as they do not address the immediate safety concern of assessing for orthostatic hypotension.
4. A healthcare provider prescribes a higher-than-usual dose of medication. What is the nurse's first action?
- A. Administer the medication and monitor closely.
- B. Hold the medication and consult the pharmacist.
- C. Ask another nurse to verify the dose.
- D. Call the provider for clarification.
Correct answer: D
Rationale: The correct answer is to call the provider for clarification. When faced with a higher-than-usual dose of medication, the nurse's first action should be to contact the prescribing healthcare provider to confirm the dosage. Administering the medication without clarifying the dose with the provider can pose serious risks to the patient's safety. Holding the medication and consulting the pharmacist may be appropriate after contacting the provider for clarification. Asking another nurse to verify the dose is not the most appropriate action when dealing with an unusual prescription; direct communication with the provider is essential in such situations.
5. A client with renal calculi is admitted. What is the priority nursing intervention?
- A. Monitor urinary output every shift.
- B. Administer pain medication as ordered.
- C. Strain all urine for stones.
- D. Increase fluid intake to flush the urinary tract.
Correct answer: C
Rationale: The correct answer is to strain all urine for stones. This is the priority nursing intervention for a client with renal calculi as it helps in identifying and preventing stones from passing unnoticed. Monitoring urinary output, administering pain medication, and increasing fluid intake are important aspects of care for this client, but the priority is to ensure that any passed stones are collected and analyzed to guide further treatment.
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