ATI RN
ATI Capstone Comprehensive Assessment B
1. What is the most appropriate action for a healthcare provider to take when a patient is at risk for falls?
- A. Place the call light within the patient's reach.
- B. Apply a yellow fall risk bracelet to the patient.
- C. Assist the patient when ambulating.
- D. Ensure the patient's room is well-lit.
Correct answer: B
Rationale: The correct answer is to apply a yellow fall risk bracelet to the patient. This action helps alert staff to the patient's increased risk of falling, prompting them to implement appropriate safety measures and precautions. Placing the call light within reach (choice A) is generally important but does not specifically address fall risk. Assisting the patient when ambulating (choice C) is important but may not be sufficient alone to prevent falls. Ensuring the patient's room is well-lit (choice D) is also crucial for patient safety but does not directly address the patient's fall risk status.
2. The nurse is reviewing the record of a client with Crohn’s disease. Which of the following stool characteristics would the nurse expect to note documented in the client’s record?
- A. Chronic constipation
- B. Diarrhea
- C. Constipation alternating with diarrhea
- D. Stool constantly oozing from the rectum
Correct answer: B
Rationale: Crohn’s disease is characterized by nonbloody diarrhea of usually not more than four to five stools daily. Over time, the diarrhea episodes increase in frequency, duration, and severity. Chronic constipation (Choice A), constipation alternating with diarrhea (Choice C), and stool constantly oozing from the rectum (Choice D) are not characteristics typically associated with Crohn’s disease.
3. A client has been prescribed lithium for the treatment of bipolar disorder. Which of the following instructions should the nurse include?
- A. Avoid driving until you know how the medication affects you.
- B. Take the medication with food to prevent stomach upset.
- C. You may experience mild nausea when initiating the medication.
- D. Do not double the next dose if you miss one.
Correct answer: A
Rationale: The correct instruction for the nurse to provide is to advise the client to avoid driving until they know how the medication affects them. Lithium can lead to side effects like dizziness and drowsiness, which could impair one's ability to drive safely. Choice B is incorrect because lithium is usually taken on an empty stomach. Choice C may be true but is not as critical as the potential side effects affecting driving. Choice D is important but not as immediate as ensuring the client's safety while driving.
4. What is the expected finding in a patient with compartment syndrome?
- A. Unrelieved pain, pallor, and pulselessness
- B. Localized swelling and redness
- C. Numbness and tingling
- D. Fever and infection
Correct answer: A
Rationale: In a patient with compartment syndrome, the expected finding includes unrelieved pain, pallor, and pulselessness. These are classic signs of compartment syndrome and indicate compromised blood flow and tissue perfusion, necessitating urgent intervention. Choices B, C, and D are incorrect because localized swelling and redness, numbness and tingling, as well as fever and infection, are not typical findings associated with compartment syndrome.
5. A male patient calls to tell the nurse that his monthly lithium level is 1.7 mEq/L. Which nursing intervention will the nurse implement initially?
- A. Reinforce that the level is above the therapeutic range.
- B. Instruct the patient to hold the next dose of medication and contact the prescriber.
- C. Advise the patient to go to the hospital emergency room immediately.
- D. Inform the patient about the possibility of seizures and appropriate precautions.
Correct answer: B
Rationale: A lithium level of 1.7 mEq/L is above the therapeutic range, indicating a potential risk of toxicity. The initial nursing intervention should be to instruct the patient to hold the next dose of medication and promptly contact the prescriber for further guidance and management. This action aims to prevent adverse effects and ensure the patient's safety by addressing the elevated lithium level appropriately.
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