ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. When the nurse discovers a patient on the floor, and the patient states, 'I fell out of bed,' the nurse assesses the patient and then places the patient back in bed. What action should the nurse take next?
- A. Re-assess the patient.
- B. Complete an incident report.
- C. Notify the healthcare provider.
- D. Do nothing, as no harm has occurred.
Correct answer: C
Rationale: After a patient has fallen, it is crucial to notify the healthcare provider. The provider needs to be informed so that further assessment, evaluation, or intervention can be carried out to ensure the patient's safety and well-being. Re-assessing the patient (Choice A) is important but notifying the healthcare provider takes precedence. Completing an incident report (Choice B) is necessary but should follow notifying the healthcare provider. Doing nothing (Choice D) is not appropriate as patient safety and potential underlying issues need to be addressed promptly.
2. A newly licensed nurse is giving a change-of-shift report using I-SBAR to an oncoming nurse. Which of the following statements by the newly licensed nurse should be included in the 'Background' portion of the report?
- A. The client has a new prescription for incentive spirometry
- B. The client's partner plans to return later today
- C. The client has no living family members
- D. I initiated a consultation with a nutritionist
Correct answer: C
Rationale: In the 'Background' portion of the report, the nurse should include relevant historical information about the client, such as the fact that the client has no living family members. This information helps provide a more comprehensive understanding of the client's situation. Choices A, B, and D are not typically included in the 'Background' section as they do not pertain to the client's history or background.
3. A client with hyperthyroidism is prescribed propranolol. Which finding indicates that the propranolol is effective?
- A. The client reports an increase in weight
- B. The client has a decrease in blood pressure
- C. The client reports an increase in energy
- D. The client's respiratory rate has increased
Correct answer: B
Rationale: The correct answer is B because a decrease in blood pressure is an expected outcome when propranolol, a beta-blocker, is effectively managing hyperthyroidism. Propranolol helps control symptoms such as tachycardia and hypertension associated with hyperthyroidism. Choices A, C, and D are incorrect because weight gain, increased energy, and an increased respiratory rate are not direct indicators of propranolol's effectiveness in treating hyperthyroidism.
4. A patient with a urinary catheter reports discomfort. What is the nurse's priority action?
- A. Ensure the catheter tubing is not kinked.
- B. Irrigate the catheter to relieve the discomfort.
- C. Change the catheter to a smaller size.
- D. Remove the catheter and replace it with a new one.
Correct answer: A
Rationale: The correct answer is to ensure the catheter tubing is not kinked. This is the priority action because a kinked tubing can obstruct urine flow, leading to discomfort and potential complications. It is essential to troubleshoot the current catheter first before considering other interventions. Irrigating the catheter (Choice B) may not address the underlying issue of kinking. Changing the catheter to a smaller size (Choice C) or removing and replacing it with a new one (Choice D) should only be considered if ensuring the tubing is unkinked does not resolve the discomfort.
5. A healthcare provider is assessing a client who has carpal tunnel syndrome. The provider should expect which of the following findings?
- A. Positive Chvostek's sign
- B. Cool extremities
- C. Positive Phalen's sign
- D. Decreased radial pulse
Correct answer: C
Rationale: Phalen's sign is often positive in clients with carpal tunnel syndrome due to nerve compression. Chvostek's sign (Choice A) is related to hypocalcemia, cool extremities (Choice B) are not typically associated with carpal tunnel syndrome, and decreased radial pulse (Choice D) is not a common finding in carpal tunnel syndrome.
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