ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B
1. Which question is essential during screening for alcohol use disorder?
- A. What is your current employment status?
- B. Have you experienced any blackouts or loss of consciousness?
- C. Have you been sleeping well over the past month?
- D. Do you have a family history of substance use?
Correct answer: B
Rationale: The essential question during screening for alcohol use disorder is asking about blackouts or loss of consciousness, which can be indicative of excessive drinking and related to alcohol use disorder. Choices A, C, and D are not as directly related to screening for alcohol use disorder. Employment status (Choice A) is not a primary question in alcohol use disorder screening. Sleep quality (Choice C) and family history of substance use (Choice D) may be relevant but are not as crucial as inquiring about blackouts or loss of consciousness.
2. A nurse is caring for a client who is postoperative following a cholecystectomy and reports pain. Which of the following actions should the nurse take? (SATA)
- A. Change the client's position
- B. Identify the client's pain level
- C. Remind the client to use incisional splinting
- D. Offer the client a back rub
Correct answer: A
Rationale: The correct actions the nurse should take when caring for a client postoperative following a cholecystectomy and reporting pain include changing the client's position. This can help relieve postoperative pain by reducing pressure on the surgical site. Identifying the client's pain level is important but not specific to alleviating postoperative pain. While reminding the client to use incisional splinting can be beneficial, it may not directly address the immediate pain concern. Offering the client a back rub is not typically indicated for postoperative pain relief after a cholecystectomy.
3. A healthcare professional is preparing to administer the initial dose of ceftriaxone to a client who has endometritis. Which of the following statements by the client should cause the healthcare professional to hold the medication and consult the provider?
- A. I have a severe allergy to amoxicillin
- B. I get sick when I take diuretics
- C. I have a history of hearing problems
- D. I take prednisone for my asthma
Correct answer: A
Rationale: A severe allergy to amoxicillin could indicate a potential cross-reactivity with ceftriaxone, so the medication should be held. Cross-reactivity between penicillins (like amoxicillin) and cephalosporins (like ceftriaxone) is a known concern due to their similar chemical structures. Choices B, C, and D do not directly contraindicate the administration of ceftriaxone for endometritis.
4. A patient has impaired skin integrity, and a nurse is providing care. What action should the nurse take to promote healing?
- A. Apply a dry, sterile dressing to the wound.
- B. Use sterile saline to clean the wound.
- C. Apply a warm compress to promote circulation.
- D. Keep the wound open to air for faster healing.
Correct answer: B
Rationale: The correct action to promote healing in a patient with impaired skin integrity is to use sterile saline to clean the wound. Sterile saline helps prevent infection and promotes healing of wounds by keeping the area clean. Applying a dry, sterile dressing (Choice A) may not be effective as it does not address the need for wound cleaning. Applying a warm compress (Choice C) may not be suitable for all types of wounds and could potentially cause harm. Keeping the wound open to air (Choice D) is generally not recommended as it can lead to infection and slow down the healing process.
5. A healthcare provider is caring for a client who has heart failure and is prescribed enalapril. The provider should monitor the client for which of the following adverse effects?
- A. Hypertension
- B. Hypokalemia
- C. Hyperglycemia
- D. Hyperkalemia
Correct answer: D
Rationale: Corrected Question: When a client with heart failure is prescribed enalapril, monitoring for hyperkalemia is essential. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can lead to an increase in potassium levels in the blood. This adverse effect can be serious and potentially life-threatening. Choices A, B, and C are incorrect because enalapril does not typically cause hypertension, hypokalemia, or hyperglycemia as adverse effects. It's essential for healthcare providers to be vigilant in monitoring potassium levels when clients are on ACE inhibitors like enalapril.
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