ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. Which intervention should be prioritized for a client experiencing panic-level anxiety?
- A. Postpone health teaching until anxiety subsides
- B. Encourage participation in group therapy
- C. Monitor vital signs every 5 minutes
- D. Provide reassurance and remain with the client
Correct answer: D
Rationale: During panic-level anxiety, the priority is to provide reassurance and remain with the client. This intervention helps to offer immediate support, comfort, and a sense of safety to the client. Postponing health teaching until anxiety subsides (Choice A) is not appropriate as the client's immediate emotional needs are more critical. Encouraging participation in group therapy (Choice B) may be beneficial in the long term but is not the priority during a panic attack. While monitoring vital signs (Choice C) is important, providing reassurance and support take precedence in managing panic-level anxiety.
2. A nurse suspects a colleague of diverting narcotics. What is the nurse's first course of action?
- A. Confront the colleague directly about the suspicion.
- B. Report the suspicion to the nurse manager.
- C. Ignore the situation unless there is clear evidence.
- D. Keep a record of the colleague's actions for future reference.
Correct answer: B
Rationale: The correct first course of action for a nurse suspecting a colleague of diverting narcotics is to report the suspicion to the nurse manager. Confronting the colleague directly may not be safe and could compromise the investigation. Ignoring the situation is not appropriate as it can pose risks to patient safety. Keeping a record of the colleague's actions is not the primary action to take when drug diversion is suspected; reporting to the nurse manager is crucial for proper investigation and ensuring patient safety.
3. When caring for a client's tracheostomy at home, which instruction should the nurse include in the teaching?
- A. Clean with alcohol
- B. Cover the tracheostomy when outside
- C. Replace the tube weekly
- D. Use tap water to clean
Correct answer: B
Rationale: Covering the tracheostomy when outside is crucial as it helps prevent dust and other irritants from entering the airway, reducing the risk of complications. Cleaning with alcohol (choice A) can be too harsh for the skin around the tracheostomy site. While replacing the tube weekly (choice C) is important, it is typically done by healthcare providers. Using tap water to clean (choice D) is not recommended as it may introduce contaminants to the tracheostomy site.
4. A nurse is assessing a postoperative patient for signs of infection. Which finding is most concerning?
- A. Mild redness at the incision site.
- B. Increased drainage from the surgical site.
- C. Fever of 101°F.
- D. Normal white blood cell count.
Correct answer: C
Rationale: A fever of 101°F is the most concerning finding when assessing a postoperative patient for signs of infection. Fever can indicate an inflammatory response to an infection, and in a postoperative patient, it can signal a surgical site infection or a systemic infection. Prompt attention is necessary to prevent complications such as sepsis. Mild redness at the incision site and increased drainage can be expected in the early postoperative period due to the normal healing process. A normal white blood cell count does not rule out infection as it can be influenced by various factors, and some infections may not initially cause a rise in white blood cells.
5. A client with HIV-1 starting therapy with ritonavir and zidovudine asks why both medications are necessary. What explanation should the nurse provide?
- A. Taking two medications ensures a faster recovery.
- B. The medications work best together to improve your immune system.
- C. Taking the 2 medications together keeps you from becoming resistant to either of them.
- D. These medications target different parts of the virus.
Correct answer: C
Rationale: The correct answer is C because taking two medications together helps prevent the development of drug resistance in HIV treatment. Choice A is incorrect because the primary goal of combination therapy is not necessarily a faster recovery. Choice B is incorrect as the main purpose of combining medications in HIV treatment is to prevent resistance rather than improving the immune system. Choice D is incorrect because while it is true that the medications may target different parts of the virus, the main reason for using both together is to prevent resistance.
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