ATI RN
ATI Capstone Comprehensive Assessment B
1. Which action by the nurse will help prevent ventilator-associated pneumonia (VAP) in a patient on mechanical ventilation?
- A. Provide oral care every 4 hours.
- B. Reposition the patient every 2 hours.
- C. Suction the patient as needed.
- D. Administer antibiotics as prescribed.
Correct answer: A
Rationale: The correct answer is A. Providing oral care every 4 hours helps prevent ventilator-associated pneumonia by reducing the buildup of bacteria in the mouth that can be aspirated into the lungs. Repositioning the patient every 2 hours is important for preventing pressure ulcers but is not directly related to preventing VAP. Suctioning the patient as needed is essential for maintaining airway patency but does not specifically prevent VAP. Administering antibiotics as prescribed is a treatment for infections but does not prevent VAP.
2. What is the most important intervention for a patient with suspected DVT?
- A. Administer anticoagulants
- B. Monitor oxygen levels
- C. Apply compression stockings
- D. Encourage ambulation
Correct answer: A
Rationale: The correct answer is to administer anticoagulants. Administering anticoagulants is crucial in the management of deep vein thrombosis (DVT) as it helps prevent the clot from growing larger or dislodging, potentially causing a life-threatening pulmonary embolism. While monitoring oxygen levels, applying compression stockings, and encouraging ambulation are important aspects of DVT management, administering anticoagulants is the most critical intervention to prevent further complications.
3. A nurse is preparing to administer a medication through a nasogastric (NG) tube. What action should the nurse take first?
- A. Flush the NG tube with 60 mL of water
- B. Verify tube placement
- C. Crush the medications and dissolve them in water
- D. Administer all medications together
Correct answer: B
Rationale: Verifying tube placement is the priority before administering any medications through a nasogastric tube. This step ensures that the tube is correctly positioned in the stomach to prevent complications such as aspiration. Flushing the tube with water, crushing medications, or administering them together should only be done after confirming the correct placement of the NG tube. Therefore, option B is the correct first action to take in this scenario.
4. Pain medications given to the burn clients are best given via what route?
- A. IV C. Oral
- B. IM D. SQ
- C.
- D.
Correct answer: C
Rationale: Effective nursing care involves comprehensive assessments that address all aspects of a patient's condition, ensuring that interventions are appropriately targeted and outcomes are optimized.
5. Which action demonstrates primary prevention?
- A. Administering immunizations
- B. Screening for early signs of disease
- C. Providing rehabilitation services
- D. Offering smoking cessation programs
Correct answer: A
Rationale: Administering immunizations is a prime example of primary prevention because it focuses on preventing diseases before they occur. By administering vaccines, individuals are protected from various infectious diseases, thereby reducing the risk of illness and transmission to others. This proactive approach aligns with the primary prevention goal of promoting health and preventing the onset of diseases.
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