ATI RN
RN ATI Capstone Proctored Comprehensive Assessment A Questions
Question 1 of 5
A client complains of pain in their leg, and the nurse notes swelling and pallor. What is the priority nursing action?
Correct Answer: D
Rationale: The correct answer is D: Notify the provider immediately about the symptoms. Swelling and pallor in a limb can be indicative of serious circulatory issues or compartment syndrome. It is crucial to inform the healthcare provider promptly to assess and address the situation. Administering pain medication (choice
A) may temporarily alleviate the symptoms but does not address the underlying cause. Elevating the limb and monitoring closely (choice
B) can be beneficial but does not replace the need for immediate professional evaluation. Encouraging movement to reduce swelling (choice
C) is contraindicated in this scenario as it may worsen the condition if a circulatory issue or compartment syndrome is present.
Question 2 of 5
After unsuccessful alternatives, a patient requires restraints. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care?
Correct Answer: A
Rationale: In the context of restraining a patient, it is crucial for the health care provider to specify the type and location of the restraint in the order to ensure the safety and well-being of the patient. This information helps guide the nursing staff in the safe application of restraints. Renewing orders every 24 hours ensures that the need for restraints is continually assessed, promoting patient safety. Performing a face-to-face assessment before ordering restraints allows for a thorough evaluation of the patient's condition and the necessity of using restraints. Ordering restraints PRN (as needed) is not appropriate for safe care as it lacks specificity and may lead to inconsistent application and monitoring.
Question 3 of 5
What is the most important action for the nurse to take before administering digoxin to a patient?
Correct Answer: A
Rationale: The correct answer is to check the patient's heart rate before administering digoxin. Digoxin is a medication that primarily affects cardiac function. Monitoring the heart rate is crucial because digoxin can cause arrhythmias or worsen existing heart rhythm abnormalities. Assessing blood pressure may also be important but is secondary to evaluating the heart rate when administering digoxin. Ensuring the patient has eaten before administration is not directly related to the safe administration of digoxin. Monitoring the patient's weight is not a priority action before administering digoxin.
Question 4 of 5
A nurse sees a healthcare provider administer an incorrect medication dose but does not report the error. What should the nurse do first?
Correct Answer: B
Rationale: When a nurse witnesses a healthcare provider administering an incorrect medication dose, the first step should be to report the error to the nurse manager immediately. Reporting medication errors is crucial for patient safety as it allows prompt intervention to prevent harm.
Choice A is incorrect as ignoring the situation can jeopardize patient safety.
Choice C, while addressing the error directly, may not ensure proper documentation and follow-up.
Choice D, filing an anonymous report, is not as effective as directly informing the nurse manager who can take appropriate action and follow-up on the incident.
Question 5 of 5
A client complains of pain in the leg while in skeletal traction. What is the nurse's priority action?
Correct Answer: B
Rationale: The correct answer is B: Check for signs of infection. In skeletal traction, the priority action for the nurse when a client complains of pain in the leg is to first assess for signs of infection. Pain in skeletal traction can be a symptom of infection or other complications, so checking for signs of infection is crucial before considering other interventions. Increasing pain medication immediately (
Choice
A) may mask the symptoms of an underlying infection. Repositioning the client's leg for comfort (
Choice
C) may provide temporary relief but does not address the potential underlying issue. Notifying the physician of the client's complaints (
Choice
D) is important but assessing for infection should come first to ensure timely and appropriate intervention.