ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form A
1. Which of the following is a common manifestation of opioid withdrawal?
- A. Bradycardia and hypotension
- B. Tremors and increased blood pressure
- C. Severe muscle weakness and fatigue
- D. Severe hallucinations and delusions
Correct answer: B
Rationale: The correct answer is B: Tremors and increased blood pressure. During opioid withdrawal, individuals commonly experience symptoms such as tremors, increased blood pressure, and restlessness. Choice A, which suggests bradycardia and hypotension, is incorrect as opioid withdrawal often leads to tachycardia (rapid heart rate) and increased blood pressure. Choice C, severe muscle weakness and fatigue, is not a typical manifestation of opioid withdrawal. Choice D, severe hallucinations and delusions, is more characteristic of conditions like delirium tremens associated with alcohol withdrawal, rather than opioid withdrawal.
2. A healthcare provider is providing teaching for a patient with a prescription for oral metronidazole, what is the priority teaching point?
- A. Report headaches
- B. Report a rash
- C. Avoid sunlight
- D. Take with meals
Correct answer: B
Rationale: The correct answer is to 'Report a rash.' Metronidazole can cause severe adverse reactions like Stevens-Johnson syndrome, a life-threatening rash. It is crucial to educate the patient to report any rash immediately to prevent serious complications. Choices A, C, and D are incorrect because while they may be relevant to consider during metronidazole therapy, they are not the priority teaching point. Headaches can occur but are not as serious as a rash; avoiding sunlight is more related to doxycycline, not metronidazole; and taking with meals is a general instruction for some medications but not the priority teaching point for metronidazole.
3. A nurse is assessing a client's wound dressing and observes a watery red drainage. The nurse should document this drainage as which of the following?
- A. Purulent
- B. Serous
- C. Sanguineous
- D. Serosanguineous
Correct answer: D
Rationale: The correct answer is D, serosanguineous. Serosanguineous drainage is thin, watery, and pale red, indicating a mixture of serous fluid and blood. Choice A (purulent) refers to thick, yellow or green drainage indicating infection. Choice B (serous) is thin, clear drainage. Choice C (sanguineous) is bright red, indicating fresh bleeding.
4. Which finding in a postoperative patient requires immediate intervention by the nurse?
- A. Heart rate of 88 beats per minute.
- B. Blood pressure of 130/80 mmHg.
- C. Crackles heard in the lung bases.
- D. Oxygen saturation of 88% on room air.
Correct answer: D
Rationale: In a postoperative patient, an oxygen saturation level of 88% on room air indicates a significant drop below the normal range, suggesting potential respiratory distress. This finding requires immediate intervention by the nurse to ensure the patient receives adequate oxygenation. A heart rate of 88 beats per minute is within the normal range, making it a less concerning finding. A blood pressure of 130/80 mmHg falls within the normal range for blood pressure and does not require immediate intervention. Crackles heard in the lung bases may indicate fluid accumulation but may not always require immediate intervention unless accompanied by other concerning signs or symptoms.
5. A client has an indwelling urinary catheter. Which of the following interventions should the nurse implement to prevent infection?
- A. Change the catheter every 72 hours.
- B. Ensure the tubing is unkinked.
- C. Empty the drainage bag every 4 hours.
- D. Hang the drainage bag below the bladder.
Correct answer: D
Rationale: The correct answer is to hang the drainage bag below the bladder. This positioning helps prevent backflow of urine, reducing the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may increase infection risk by introducing pathogens. Ensuring the tubing is unkinked promotes proper urine flow but does not directly prevent infection. Emptying the drainage bag regularly is important to prevent urinary stasis but does not directly address infection prevention.
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