Extract:

Question 1 of 5

A nurse is observing an assistive personnel (AP) measure blood pressures from the right arms of a group of clients. The nurse should instruct the AP to measure the blood pressure in the left arm of which of the following clients?

A. A client who has a right peripherally inserted central catheterB. A client who had a right hemisphere strokeC. A client who had blood drawn from the right antecubital area 1 hr agoD. A client who had dialysis and is using an arteriovenous shunt in the left lower forearmG. A

Correct Answer: A right-sided PICC interferes with accurate blood pressure readings; use the left arm. Other conditions do not necessitate left-arm measurement.

Rationale:

Question 2 of 5

A nurse is planning assignments for the upcoming shift. Which of the following tasks should the nurse delegate to an assistive personnel?

A. Instruct a client on the use of an incentive spirometer.B. Insert an NG tube for a client who requires enteral feedings.C. Obtain a client's vital signs every 4 hr.D. Record a client's intake after each meal.E. Transfer a client to physical therapy.G. C,D,E

Correct Answer: Assistive personnel can obtain vital signs, record intake, and transfer clients. Teaching and NG tube insertion require licensed nurse skills.

Rationale:

Question 3 of 5

A school nurse is using the Weber's test to check a child's hearing acuity. Which of the following actions should the nurse take?

A. Hold a vibrating tuning fork 1 to 2 cm (0.4 to 0.8 in) from the child's ears.B. Measure the amount of time the child can hear the sound.C. Obtain a tympanogram reading prior to initiating the test.D. Place a vibrating tuning fork on the top of the child's head.G. D

Correct Answer: Placing a tuning fork on the head assesses sound lateralization in Weber's test. Other actions are not part of this procedure.

Rationale:

Question 4 of 5

A community health nurse is developing a plan of care for an older adult client who has type 2 diabetes mellitus and lives independently in a rural area. Which of the following interventions should the nurse include?

A. Suggest that the client attend adult day care three times per week.B. Review assisted living accommodations with the client.C. Discuss a long-term care referral for the client with the provider.D. Instruct the client about the use of telehealth services.G. D

Correct Answer: Telehealth services support diabetes management in rural areas by providing remote monitoring and education, promoting independence. Adult day care, assisted living, or long-term care may not be necessary for an independent client.

Rationale:

Question 5 of 5

A charge nurse is observing assistive personnel perform delegated tasks. Which of the following actions by the AP requires the charge nurse to intervene?

A. Performing a simple dressing change on a client's footB. Washing hands with alcohol-based hand rub after bathing a client who has Clostridium difficileC. Providing postmortem care for a client who has recently diedD. Emptying an indwelling urinary catheter bag for a client while wearing clean glovesG. B

Correct Answer: Alcohol-based rubs are ineffective against C. difficile; soap and water are required. Other actions are within AP scope.

Rationale:

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RN ATI Capstone Proctored Comprehensive Assessment Form B Questions

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