ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A client has a new prescription for a cane. What instruction 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: 'Ensure the cane has a rubber tip.' This instruction is essential for safety as the rubber tip prevents slipping, providing stability. Choice A is incorrect because the cane should be held on the stronger side to provide better support and balance. Choice C is incorrect as the cane should be used on the stronger, more dominant side. Choice D is also incorrect as a cane is not only used on stairs but also for general support and mobility.
2. A nurse is caring for a client who reports pain and burning around the peripheral IV site. What is the nurse's priority action?
- A. Apply a warm compress
- B. Discontinue the IV line
- C. Increase the IV flow rate
- D. Elevate the limb
Correct answer: B
Rationale: The correct answer is B: Discontinue the IV line. When a client reports pain and burning around the peripheral IV site, it indicates possible phlebitis, which is inflammation of the vein. The priority action is to discontinue the IV line to prevent further complications such as infection or thrombosis. Applying a warm compress (Choice A) may worsen the inflammation. Increasing the IV flow rate (Choice C) can exacerbate the symptoms and elevate the risk of complications. Elevating the limb (Choice D) may provide comfort, but it does not address the underlying issue of phlebitis. Therefore, the priority action is to discontinue the IV line.
3. A nurse is caring for a client who reports burning around the peripheral IV site. What finding should the nurse identify as a manifestation of infiltration?
- A. Bruising at the IV site
- B. Edema at the IV site
- C. Warmth along the IV site
- D. Pallor at the IV site
Correct answer: B
Rationale: Edema at the IV site is a common sign of infiltration, where fluid leaks into the surrounding tissue. Bruising at the IV site (Choice A) is more indicative of hematoma formation, warmth along the IV site (Choice C) may suggest infection, and pallor at the IV site (Choice D) is not a typical sign of infiltration.
4. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?
- A. Natural immunity
- B. Acquired immunity
- C. Passive immunity
- D. Cell-mediated immunity
Correct answer: B
Rationale: An immunization functions as part of acquired immunity. Acquired immunity involves the production of antibodies after immunization, which helps protect against future infections. Natural immunity is not induced by immunization but is present from birth. Passive immunity is temporary and acquired through the transfer of pre-formed antibodies. Cell-mediated immunity is a type of immune response that involves the activation of phagocytes, antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen.
5. A client who has recently developed fever, confusion, and a decreased level of consciousness is being admitted by a nurse. What should the nurse do first after obtaining the client's history and assessment?
- A. Administer prescribed antibiotics
- B. Initiate seizure precautions
- C. Identify the client's needs
- D. Place the client in isolation
Correct answer: C
Rationale: The correct answer is to identify the client's needs first. This allows the nurse to prioritize interventions based on the assessment findings. Administering prescribed antibiotics (choice A) should be based on a medical prescription and the identified infection. Initiating seizure precautions (choice B) is important but not the immediate priority in this case. Placing the client in isolation (choice D) is premature as the nurse needs to first assess and address the client's condition.
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