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. How should a nurse respond to a client with terminal cancer who has requested a change in the level of pain medication?
- A. Increase the dosage without consulting the healthcare provider.
- B. Consult with the healthcare provider to adjust the medication.
- C. Ignore the request as the client is near the end of life.
- D. Increase the medication to reduce pain faster.
Correct answer: B
Rationale: The correct answer is to consult with the healthcare provider to adjust the medication. It is crucial for the healthcare provider to be involved in changing pain medication for a client with terminal cancer to ensure that the new dosage is appropriate and safe. Option A is incorrect because adjusting medication without consulting the healthcare provider can be dangerous and is not within the scope of the nurse's practice. Option C is incorrect because ignoring the client's request goes against the principles of patient-centered care. Option D is incorrect as the primary goal should be to provide effective pain relief with the appropriate dosage, not to increase the medication arbitrarily.
3. When caring for a patient with a colostomy, which nursing action is most important?
- A. Monitor the colostomy for signs of infection.
- B. Empty the colostomy bag when it is half full.
- C. Encourage the patient to eat smaller, more frequent meals.
- D. Apply a skin barrier to prevent irritation.
Correct answer: B
Rationale: Emptying the colostomy bag when it is half full is the most important nursing action when caring for a patient with a colostomy. This practice helps prevent leakage, reduces the risk of skin irritation, and promotes patient comfort. Monitoring for signs of infection (Choice A) is essential but not as crucial as maintaining proper colostomy care. Encouraging the patient to eat smaller, more frequent meals (Choice C) can be beneficial for colostomy patients but is not as critical as ensuring timely emptying of the colostomy bag. Applying a skin barrier to prevent irritation (Choice D) is important, but ensuring timely emptying of the colostomy bag takes precedence in preventing complications associated with a colostomy.
4. A client with asthma is taking fluticasone. The nurse should monitor the client for which of the following adverse effects?
- A. Polyuria
- B. Oral candidiasis
- C. Hypertension
- D. Hypoglycemia
Correct answer: B
Rationale: Correct. Fluticasone, a corticosteroid medication commonly used to manage asthma, can lead to oral candidiasis due to its immunosuppressive effects. This fungal infection can manifest as white patches in the mouth and throat. Monitoring for signs of oral candidiasis is essential to initiate appropriate treatment. Polyuria (excessive urination) is not a common adverse effect of fluticasone. Hypertension and hypoglycemia are also not typically associated with this medication, making them incorrect choices.
5. The nurse is caring for a patient who is susceptible to infection. Which instruction will the nurse include in an educational session to decrease the risk of infection?
- A. Teaching the patient to take a temperature
- B. Teaching the patient to select nutritious foods
- C. Teaching the patient about the effects of alcohol
- D. Teaching the patient about fall prevention
Correct answer: B
Rationale: The correct answer is B: Teaching the patient to select nutritious foods. A nutritious diet plays a crucial role in strengthening the body's immune system, making it more capable of fighting off infections. Vitamins, minerals, and other nutrients found in healthy foods support immune function and overall health. Teaching the patient about taking a temperature (choice A) may be important for monitoring for signs of infection but does not directly decrease the risk of infection. Teaching about the effects of alcohol (choice C) and fall prevention (choice D) are important aspects of patient education but are not directly related to decreasing the risk of infection in a susceptible patient.
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