ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A
1. Which action by the nurse will help reduce the risk of venous thromboembolism (VTE) in a postoperative patient?
- A. Encourage early ambulation and leg exercises.
- B. Apply compression stockings to the patient's legs.
- C. Administer anticoagulants as prescribed.
- D. Elevate the patient's legs to promote circulation.
Correct answer: A
Rationale: The correct answer is to encourage early ambulation and leg exercises. By promoting early ambulation and leg exercises, blood flow is enhanced, reducing the risk of venous thromboembolism (VTE) in postoperative patients. Choice B, applying compression stockings, helps prevent VTE but is not as effective as early ambulation and exercises. Choice C, administering anticoagulants, is important in VTE prevention but does not directly address improving circulation through physical activity. Choice D, elevating the patient's legs, may be beneficial for circulation in specific cases but is not as effective in preventing VTE as early ambulation and leg exercises.
2. A nurse manager notices a discrepancy in a nurse's narcotics record. What is the appropriate action?
- A. Ask the nurse for clarification about the record.
- B. Report the discrepancy to the pharmacy.
- C. Report the issue to the nurse manager immediately.
- D. Ignore the discrepancy as a clerical error.
Correct answer: B
Rationale: The appropriate action when a nurse manager notices a discrepancy in a nurse's narcotics record is to report the discrepancy to the pharmacy. Reporting such discrepancies is crucial to ensure accountability and patient safety. Choice A is incorrect because the nurse manager should not confront the nurse directly without proper investigation. Choice C is incorrect because reporting to the nurse manager may not address the issue effectively. Choice D is incorrect because ignoring the discrepancy can compromise patient safety and violates protocols.
3. A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?
- A. Closes the door to the client's room
- B. Flushes the client's toilet after emptying the urinary catheter's drainage bag
- C. Measures the client's vital signs routinely
- D. Asks a group of personnel in the hall to speak quietly
Correct answer: B
Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.
4. A nurse is caring for a female client who has osteoporosis and a new prescription for raloxifene. What should the nurse assess prior to initiating therapy?
- A. Pregnancy status
- B. Bone density
- C. Calcium levels
- D. Blood pressure
Correct answer: A
Rationale: The correct answer is A: Pregnancy status. Raloxifene is a pregnancy category X drug, which means it can cause serious birth defects. Therefore, it is crucial for the nurse to assess the client's pregnancy status before initiating therapy. Choice B, bone density, while important in osteoporosis management, is not a specific concern related to initiating raloxifene therapy. Choice C, calcium levels, and choice D, blood pressure, are not directly related to the initiation of raloxifene therapy in a female client with osteoporosis.
5. A nurse manager on an acute care unit is preparing a staff presentation about promoting cost-effective care. Which of the following strategies should the nurse plan to include in the presentation?
- A. Change IV solution bags every 36 hr.
- B. Avoid the delegation of hygiene care to assistive personnel (AP)
- C. Wear sterile gloves when removing urinary retention catheters.
- D. Educate staff about the correct use of personal protective equipment (PPE) for isolation precautions
Correct answer: D
Rationale: Teaching staff proper use of PPE helps reduce the spread of infections and promotes cost-effective care.
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