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 NeurologyEXAM > RN ATI Capstone Comprehensive Assessment A1. "While I take this medication, I should eat a high-protein diet." 2. "I should change positions slowly at first so I don't get dizzy." 3. "If I have muscle twitching, I should report it to my health care provider." 4. "I should check with my health care provider before taking any over-the-counter medications." 1) CORRECT- Implementation: outcome not desired; take with low-protein diet to decrease GI upset 2) Implementation: outcome desired; true; orthostatic hypotension is common with Parkinson's disease 3) Implementation: outcome desired; true; blepharospasms (twitching eyelid) are early signs of overdosage 4) Implementation: outcome desired; true; multivitamins can reverse actions, especially vitamin B6 The nurse cares for clients in the pediatric clinic. The nurse would be MOST concerned if which of the following was observed? 1. A 3-month-old infant's back is rounded. 2. A 4-year-old has a blood pressure of 90/60. 3. A 5-year-old has a pulse of 88. 4. The hem of the skirt on a 10-year-old is longer on one side than the other. 1) Assessment: outcome expected; normal finding 2) Assessment: outcome expected; normal finding 3) Assessment: outcome expected; normal finding 4) CORRECT-Assessment: outcome not expected; symptom of scoliosis The nurse observes a peer self-administering fentanyl (Sublimaze) after removing it from the narcotic cabinet. Which is the MOST appropriate action for the nurse to take? 1. Tell the nurse what was observed. 2. Report the observation to the supervisor. 3. Complete an incident report. 4. Discuss the incident with another nurse. 1) Implementation: outcome not desired; inappropriate; is confrontational 2) CORRECT- Implementation: outcome desired; use chain of command 3) Implementation: outcome not desired; not appropriate for situation 4) Implementation: outcome not desired; inappropriate; confidential information The nursing team consists of two RNs, one LPN/LVN, and one nursing assistive personnel. The nurse should consider the assignment appropriate if the LPN/LVN is required to complete which task? 1. Ambulate a client 8 hours after a thoracotomy. 2. Give an enema to a client prior to a colonoscopy. 3. Complete a bed bath for a client with burns on the arms and legs. 4. Perform a dressing change on a client 3 days after a cholecystectomy. 1) Implementation: outcome not desired; RN needs to frequently assess and evaluate 2) Implementation: outcome not desired; standard, unchanging procedure, assign to assistive personnel 3) Implementation: outcome not desired: high risk of infection and sepsis, RN can do thorough assessment during bath 4) CORRECT- Implementation: outcome desired; stable client with an expected outcome (All)

RN ATI Capstone Comprehensive Assessment A1. "While I take this medication, I should eat a high-protein diet." 2. "I should change positions slowly at first so I don't get dizzy." 3. "If I have muscle twitching, I should report it to my health care provider." 4. "I should check with my health care provider before taking any over-the-counter medications." 1) CORRECT- Implementation: outcome not desired; take with low-protein diet to decrease GI upset 2) Implementation: outcome desired; true; orthostatic hypotension is common with Parkinson's disease 3) Implementation: outcome desired; true; blepharospasms (twitching eyelid) are early signs of overdosage 4) Implementation: outcome desired; true; multivitamins can reverse actions, especially vitamin B6 The nurse cares for clients in the pediatric clinic. The nurse would be MOST concerned if which of the following was observed? 1. A 3-month-old infant's back is rounded. 2. A 4-year-old has a blood pressure of 90/60. 3. A 5-year-old has a pulse of 88. 4. The hem of the skirt on a 10-year-old is longer on one side than the other. 1) Assessment: outcome expected; normal finding 2) Assessment: outcome expected; normal finding 3) Assessment: outcome expected; normal finding 4) CORRECT-Assessment: outcome not expected; symptom of scoliosis The nurse observes a peer self-administering fentanyl (Sublimaze) after removing it from the narcotic cabinet. Which is the MOST appropriate action for the nurse to take? 1. Tell the nurse what was observed. 2. Report the observation to the supervisor. 3. Complete an incident report. 4. Discuss the incident with another nurse. 1) Implementation: outcome not desired; inappropriate; is confrontational 2) CORRECT- Implementation: outcome desired; use chain of command 3) Implementation: outcome not desired; not appropriate for situation 4) Implementation: outcome not desired; inappropriate; confidential information The nursing team consists of two RNs, one LPN/LVN, and one nursing assistive personnel. The nurse should consider the assignment appropriate if the LPN/LVN is required to complete which task? 1. Ambulate a client 8 hours after a thoracotomy. 2. Give an enema to a client prior to a colonoscopy. 3. Complete a bed bath for a client with burns on the arms and legs. 4. Perform a dressing change on a client 3 days after a cholecystectomy. 1) Implementation: outcome not desired; RN needs to frequently assess and evaluate 2) Implementation: outcome not desired; standard, unchanging procedure, assign to assistive personnel 3) Implementation: outcome not desired: high risk of infection and sepsis, RN can do thorough assessment during bath 4) CORRECT- Implementation: outcome desired; stable client with an expected outcome

Capstone_Comprehensive_Assessment_A

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