RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

Correct Answer: B

Rationale: The correct answer is to monitor for signs of infection. After major surgery, one of the priority nursing assessments is to watch for signs of infection, such as increased temperature, redness, swelling, or drainage at the surgical site. While providing analgesia is important for pain management, monitoring for infection takes precedence as it can lead to severe complications if not detected early. Assessing the surgical site for bleeding is crucial but is usually more relevant immediately after surgery. Monitoring the patient's vital signs is essential, but the specific focus on infection assessment is crucial in the immediate postoperative period.

Correct Answer: B

Rationale: The correct answer is B: 'Eliminate areas of standing water.' This is an essential primary prevention strategy for West Nile virus as it helps prevent the breeding of mosquitoes that spread the virus. Choices A, C, and D are incorrect. Avoiding exposure to deer ticks is more relevant for Lyme disease, using a respiratory mask when cleaning bird coops is not a primary prevention strategy for West Nile virus, and planning outdoor activities after dusk does not directly address the prevention of West Nile virus transmission.

Correct Answer: B

Rationale: The correct answer is B: Gastrointestinal distress. When taking Lithium Carbonate, clients may experience gastrointestinal distress as an adverse effect. It is crucial to educate clients about this potential side effect to help them manage it effectively. Choices A, C, and D are incorrect. Increased risk of infection (Choice A) is not a typical adverse effect of Lithium Carbonate. Similarly, increased white blood cell count (Choice C) is not associated with this medication's adverse effects. Nausea and vomiting (Choice D) are general side effects of many medications but are not specifically attributed to Lithium Carbonate.

Correct Answer: A

Rationale: The correct action for the nurse to include in the plan of care for an older adult at risk for falls is to lock beds and wheelchairs when not in use. This measure is crucial for preventing falls and ensuring patient safety in healthcare settings. Administering sedatives at bedtime (Choice B) is not recommended as it does not address the underlying risk factors for falls and may increase the risk of injury. Providing information about home safety checks (Choice C) is important for fall prevention in the home environment but is not directly related to healthcare settings. Teaching balance and strengthening exercises (Choice D) is beneficial for fall prevention but may not be suitable for all older adults at risk for falls, especially in acute care settings.

Correct Answer: A

Rationale: The correct answer is A. Instructing the client to remain still once the gel pads are attached is crucial to obtaining accurate ECG readings. Choice B is incorrect as electrodes are typically placed on the chest, not the breast. Choice C is incorrect because the client should lie flat during an ECG, not sit up. Choice D is incorrect because the client should breathe normally, rather than holding their breath, throughout the procedure.