A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

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RN ATI Capstone Proctored Comprehensive Assessment Form A Questions

Question 1 of 5

A client reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene?

Correct Answer: B

Rationale: The correct answer is B because flushing the client's toilet after emptying the urinary catheter's drainage bag could disturb the client's rest. The nurse should intervene to ensure a restful environment for the client. Choices A, C, and D are not actions that would be disruptive to the client's sleep. Closing the door to the client's room, measuring vital signs routinely, and asking personnel in the hall to speak quietly are appropriate actions that do not directly disturb the client's rest.

Question 2 of 5

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

Correct Answer: B

Rationale: The correct answer is B because cleaning the hearing aids with alcohol wipes can damage them. It is important to use specialized cleaning tools or follow specific cleaning instructions provided by the manufacturer to prevent harm to the hearing aids. Choices A, C, and D demonstrate good understanding and appropriate care for hearing aids, indicating that the client does not need further instruction in those areas.

Question 3 of 5

A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?

Correct Answer: B

Rationale: After a flexible bronchoscopy, it is essential to withhold food and liquids until the client's gag reflex returns. This precaution helps prevent aspiration, as the gag reflex protects the airway from foreign material. Irrigating the client's throat every 4 hours (Choice A) is unnecessary and may increase the risk of aspiration. Suctioning the client's oropharynx frequently (Choice C) can cause trauma and is not indicated unless there is a specific medical reason for it. Having the client refrain from talking for 24 hours (Choice D) is not necessary after a flexible bronchoscopy.

Question 4 of 5

A nurse is preparing to administer digoxin 0.25 mg PO daily. The amount available is digoxin 0.125 mg tablets. How many tablets should the nurse administer?

Correct Answer: B

Rationale: The correct answer is B: 2. To achieve the prescribed dose of 0.25 mg of digoxin, the nurse should administer two 0.125 mg tablets. This calculation ensures that the patient receives the correct amount of medication. Choices A, C, and D are incorrect because they do not reflect the accurate dosage needed based on the available tablets and prescribed dose.

Question 5 of 5

A client has urinary incontinence, and the nurse is caring for them. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Correct Answer: C

Rationale: The correct action to prevent skin breakdown in a client with urinary incontinence is to apply a moisture barrier ointment to the skin. This ointment helps protect the skin from the harmful effects of moisture exposure, reducing the risk of breakdown. Requesting an indwelling urinary catheter (Choice A) should not be the first-line intervention for skin breakdown prevention. Checking the client's skin for signs of breakdown (Choice B) is important but not as effective as applying a moisture barrier. Cleaning the skin with hot water (Choice D) can actually be detrimental as hot water can strip the skin of its natural oils and worsen skin integrity.

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