ATI RN
ATI Capstone Comprehensive Assessment B
1. What should be done to ensure safety during the transfer of a patient with limited mobility?
- A. Have the patient use a gait belt for support.
- B. Encourage the patient to hold onto a walker.
- C. Lock the wheels on the bed and wheelchair.
- D. Ask the patient to transfer independently.
Correct answer: C
Rationale: The correct answer is to lock the wheels on the bed and wheelchair. This action helps prevent accidents by stabilizing the equipment during the transfer process. Having the patient use a gait belt for support (choice A) can be helpful but is not directly related to equipment safety. Encouraging the patient to hold onto a walker (choice B) is beneficial for ambulation but does not address the safety of equipment. Asking the patient to transfer independently (choice D) can pose risks, especially for a patient with limited mobility, and may not ensure safety during the transfer.
2. A nurse is caring for a client who has diarrhea due to shigella. Which of the following precautions should the nurse take?
- A. Wear gloves only
- B. Wear a mask
- C. Wash hands before and after client care
- D. Use an N95 respirator
Correct answer: C
Rationale: The correct precaution for a nurse caring for a client with shigella-induced diarrhea is to wash hands before and after client care. Shigella is a highly contagious bacterium that spreads through contaminated food, water, or contact with infected individuals. While wearing gloves is important when directly handling bodily fluids, hand hygiene is crucial in preventing the transmission of the infection. Wearing a mask or using an N95 respirator is not necessary for preventing the spread of shigella, as it primarily spreads through the fecal-oral route rather than through respiratory droplets.
3. What is an appropriate parenting technique for time-out disciplining in children with mental health issues?
- A. Provide positive reinforcement for minor infractions
- B. Remove all privileges for at least one week following a violation
- C. Limit the child's time outside of the home environment
- D. Time-out should only be used in severe situations
Correct answer: B
Rationale: The correct answer is B: 'Remove all privileges for at least one week following a violation.' When dealing with children with mental health issues, it is essential to have consistent consequences for their actions. Providing positive reinforcement for minor infractions (choice A) may not effectively address inappropriate behaviors that require disciplinary action. Limiting the child's time outside the home environment (choice C) does not directly address the behavioral issue. Using time-out only in severe situations (choice D) may not provide consistent consequences for the child's behavior and can lead to escalation before interventions are used.
4. 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.
5. The surgical mask the perioperative nurse is wearing becomes moist. Which action will the perioperative nurse take next?
- A. Do not change the mask if the nurse is comfortable.
- B. Change the mask when relieved by the next shift.
- C. Apply a new mask.
- D. Reapply the mask after it air-dries.
Correct answer: C
Rationale: When a surgical mask becomes moist, it loses its effectiveness as a barrier against microorganisms. Therefore, the perioperative nurse should apply a new mask. Choice A is incorrect because a moist mask should not be continued to be worn even if the nurse is comfortable. Choice B is not the best course of action as the mask should be changed immediately when it becomes moist. Choice D is also incorrect as waiting for the mask to air-dry is not recommended due to the loss of barrier effectiveness.
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