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PN ATI Capstone Fundamentals Quiz
1. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?
- A. Notify the healthcare provider
- B. Recheck the client's BP
- C. Document the findings
- D. Administer antihypertensive medication
Correct answer: B
Rationale: The correct answer is to recheck the client's BP. It is essential for the nurse to verify the accuracy of the initial reading by reassessing the blood pressure. Notifying the healthcare provider or administering antihypertensive medication should only occur after confirming the elevated blood pressure through a recheck. Documenting the findings is important but should follow the confirmation of the BP reading.
2. A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which of the following behaviors should the nurse identify as increasing the client's risk for constipation?
- A. Regular fluid intake
- B. Urge suppression
- C. Increased physical activity
- D. Adequate dietary fiber
Correct answer: B
Rationale: Urge suppression can lead to constipation by delaying bowel movements and causing fecal impaction, especially in postoperative patients. Regular fluid intake (choice A) is important to prevent constipation by maintaining hydration and aiding in bowel movements. Increased physical activity (choice C) helps stimulate bowel function and prevent constipation. Adequate dietary fiber (choice D) is essential for promoting healthy bowel movements and preventing constipation. However, urge suppression (choice B) is the behavior that directly contributes to constipation in this scenario.
3. A nurse is teaching a group of assistive personnel (AP) about the expected integumentary changes in older adults. Which should the nurse include?
- A. Increase in elasticity
- B. Decrease in pigmentation
- C. Decrease in elasticity
- D. Increase in moisture levels
Correct answer: C
Rationale: The correct answer is C: 'Decrease in elasticity.' As individuals age, they typically experience a decrease in skin elasticity, leading to sagging skin and increased wrinkles. This change in elasticity can contribute to various skin-related issues such as pressure ulcers and delayed wound healing. Choices A, B, and D are incorrect because older adults do not experience an increase in elasticity or moisture levels, and while there may be changes in pigmentation, the primary change related to aging in the integumentary system is a decrease in elasticity.
4. A client is reviewing information about advance directives with a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I understand that I can change my mind at any time.
- B. I have a living will that outlines my wishes when I am unable to make a decision.
- C. I need to inform my family about my wishes.
- D. I don’t need to worry about advance directives right now.
Correct answer: B
Rationale: The correct answer is B because having a living will indicates that the client understands and has documented their wishes regarding medical treatment when they are unable to make decisions. Choice A is incorrect because while it's true that clients can change their minds about advance directives, it doesn't specifically indicate an understanding of the teaching provided. Choice C is important but doesn't directly show if the client understands advance directives. Choice D is incorrect because it dismisses the importance of advance directives, indicating a lack of understanding.
5. A nurse is planning to administer several medications to a client through an NG tube. Which actions should the nurse take?
- A. Dissolve crushed tablet medications in tap water
- B. Use 30-40 mL of sterile water for each medication
- C. Dissolve crushed tablet medications in sterile water
- D. Administer medications without dissolving
Correct answer: C
Rationale: The correct action for the nurse to take when administering medications through an NG tube is to dissolve crushed tablet medications in 15-30 mL of sterile water. This ensures proper delivery through the NG tube and reduces the risk of clogging. Choice A is incorrect because tap water may contain impurities that can cause complications. Choice B suggests using a higher volume of sterile water than necessary, which may lead to dilution of the medications. Choice D is incorrect as medications should be dissolved to prevent blockages in the NG tube.
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