ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. When teaching a client about the correct use of a cane, what should the nurse include?
- A. Hold the cane on the weaker side
- B. Ensure the cane has a rubber tip
- C. Keep the cane on the dominant side
- D. Use the cane only on stairs
Correct answer: B
Rationale: The correct answer is B. When instructing a client on the use of a cane, it is essential to ensure that the cane has a rubber tip. This rubber tip helps prevent slipping, providing additional stability and safety. Option A, holding the cane on the weaker side, is incorrect as the cane should be held on the stronger side to provide better balance and support. Option C, keeping the cane on the dominant side, is also incorrect because the cane should be held on the stronger side. Option D, using the cane only on stairs, is not comprehensive as the cane can be used for support and balance while walking on level ground as well.
2. A nurse is teaching a group of assistive personnel about expected integumentary changes in older adults. What change should the nurse include?
- A. Increase in oil production
- B. Decrease in elasticity
- C. Increase in pigmentation
- D. Decrease in moisture levels
Correct answer: B
Rationale: The correct answer is B: Decrease in elasticity. As individuals age, their skin tends to lose elasticity, becoming less flexible. This results in wrinkles and sagging skin. Option A, increase in oil production, is not typically an expected integumentary change in older adults. Option C, increase in pigmentation, may occur due to sun exposure or age spots but is not a universal change. Option D, decrease in moisture levels, is not a primary integumentary change associated with aging.
3. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?
- A. Steamed carrots
- B. Mashed potatoes
- C. Orange slices
- D. Soft-cooked eggs
Correct answer: C
Rationale: The correct answer is C: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices have membranes that can be challenging to consume for individuals with swallowing difficulties. Steamed carrots (Choice A) and mashed potatoes (Choice B) are typically suitable for a mechanical soft diet as they can be easily mashed or cut into smaller pieces. Soft-cooked eggs (Choice D) are also appropriate for this diet as they are soft and easy to chew.
4. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What is the nurse's priority action?
- A. Flush the IV line with saline
- B. Discontinue the infusion
- C. Elevate the limb
- D. Apply a cold compress
Correct answer: B
Rationale: The correct answer is to discontinue the infusion. The symptoms described - pain, redness, and warmth along the vein - are indicative of phlebitis, which is inflammation of the vein. Continuing the infusion can lead to further complications. Flushing the IV line, elevating the limb, or applying a cold compress do not address the underlying issue of phlebitis and may not be sufficient to resolve the problem. Therefore, the priority action is to discontinue the infusion to prevent worsening of the condition.
5. A nurse is caring for a client who is undergoing surgery for a hip fracture. What is a priority intervention to reduce the risk of postoperative complications?
- A. Encourage early ambulation
- B. Provide intravenous antibiotics
- C. Apply anti-embolism stockings
- D. Place a Foley catheter to monitor output
Correct answer: A
Rationale: Encouraging early ambulation is crucial in reducing the risk of postoperative complications, such as blood clots and pneumonia. Early mobilization helps prevent complications like deep vein thrombosis and pneumonia by promoting circulation and preventing respiratory complications. Providing intravenous antibiotics (Choice B) is important for preventing infections but is not the priority immediately post-surgery. Applying anti-embolism stockings (Choice C) is beneficial in preventing venous thromboembolism but does not address the immediate need for mobility. Placing a Foley catheter (Choice D) may be necessary during surgery but is not a priority intervention to reduce postoperative complications related to immobility.
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