ATI Capstone Comprehensive Assessment B

ATI Capstone Comprehensive Assessment B Related

Review ATI Capstone Comprehensive Assessment B related questions and content

The patient experienced a surgical procedure, and Betadine was utilized as the surgical prep. Two days postoperatively, the nurse's assessment indicates that the incision is red and has a small amount of purulent drainage. The patient reports tenderness at the incision site. The patient's temperature is 100.5°F, and the WBC is 10,500/mm³. Which action should the nurse take first?

  • A. Reevaluate the temperature and white blood cell count in 4 hours.
  • B. Check which solution was used for skin preparation in surgery.
  • C. Plan to change the surgical dressing during the shift.
  • D. Utilize SBAR to notify the primary health care provider.
Correct Answer: D

Rationale: The patient is showing signs of a possible surgical site infection, including redness, purulent drainage, tenderness, elevated temperature, and increased white blood cell count. These symptoms suggest the need for immediate action to address a potential complication. Utilizing SBAR to notify the primary health care provider is crucial as it allows for effective communication of the patient's condition and the need for further assessment and intervention. Reevaluating the temperature and white blood cell count later, checking the solution used for skin preparation, or planning to change the dressing do not address the urgent need for intervention and communication with the healthcare provider.

You may also like to solve these questions

Which action by the nurse will help prevent ventilator-associated pneumonia (VAP) in a patient on mechanical ventilation?

  • A. Provide oral care every 4 hours.
  • B. Reposition the patient every 2 hours.
  • C. Suction the patient as needed.
  • D. Administer antibiotics as prescribed.
Correct Answer: A

Rationale: The correct answer is A. Providing oral care every 4 hours helps prevent ventilator-associated pneumonia by reducing the buildup of bacteria in the mouth that can be aspirated into the lungs. Repositioning the patient every 2 hours is important for preventing pressure ulcers but is not directly related to preventing VAP. Suctioning the patient as needed is essential for maintaining airway patency but does not specifically prevent VAP. Administering antibiotics as prescribed is a treatment for infections but does not prevent VAP.

When assessing a client with terminal cancer receiving a continuous intravenous infusion of morphine sulfate, what should the nurse check first?

  • A. Check for respiratory depression.
  • B. Assess pain control.
  • C. Check the infusion site for complications.
  • D. Monitor the client's blood pressure.
Correct Answer: A

Rationale: The correct answer is to check for respiratory depression first when assessing a client receiving a continuous intravenous infusion of morphine sulfate. Respiratory depression is the most common life-threatening side effect associated with morphine administration. Monitoring respiratory status is crucial as it can quickly deteriorate, leading to serious complications or even respiratory arrest. Assessing pain control (choice B) is important but ensuring adequate ventilation takes precedence. Checking the infusion site for complications (choice C) and monitoring blood pressure (choice D) are also essential aspects of care but are secondary to evaluating respiratory status when administering morphine.

A nurse is preparing to administer morphine sulfate to a client. What should the nurse assess before administration?

  • A. Assess for pain relief.
  • B. Monitor for respiratory depression.
  • C. Assess the infusion site for complications.
  • D. Increase the dosage if the client reports more pain.
Correct Answer: B

Rationale: Correct answer: Before administering morphine sulfate, the nurse should monitor for respiratory depression as it is a significant side effect of this medication. Assessing for pain relief (Choice A) is important but not a pre-administration assessment. Checking the infusion site for complications (Choice C) is relevant for IV medications, not specifically for morphine sulfate. Increasing the dosage if the client reports more pain (Choice D) is not appropriate without further assessment and medical orders.

A patient is at risk for impaired skin integrity. What is the priority intervention for the nurse?

  • A. Turn and reposition the patient every 2 hours.
  • B. Apply a moisture barrier to the patient's skin.
  • C. Massage the patient's skin to promote circulation.
  • D. Apply a heating pad to the patient's skin to increase blood flow.
Correct Answer: A

Rationale: The correct answer is to turn and reposition the patient every 2 hours. This intervention is crucial in preventing pressure ulcers and maintaining skin integrity by relieving pressure on bony prominences. Applying a moisture barrier (Choice B) is important for moisture-associated skin damage but is not the priority in this case. Massaging the patient's skin (Choice C) can potentially cause friction and shear, increasing the risk of skin breakdown. Applying a heating pad (Choice D) can lead to burns or thermal injuries, exacerbating skin integrity issues.

After placing the patient back in bed, what should the nurse do next?

  • A. Re-assess the patient.
  • B. Complete an incident report.
  • C. Notify the health care provider.
  • D. Do nothing, no harm has occurred.
Correct Answer: C

Rationale: After placing the patient back in bed, the nurse should notify the health care provider. This is important because the health care provider needs to be informed of the incident and assess the patient further to ensure no underlying injuries or issues exist. Re-assessing the patient is crucial but notifying the health care provider takes precedence in this situation. Completing an incident report is important for documentation purposes but not the immediate next step. Doing nothing is incorrect as there was an incident involving a fall that needs further evaluation.

Copyright © 2025 Nokea. All rights reserved.