ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and warm. What should the nurse do?
- A. Increase the IV flow rate
- B. Discontinue the IV line
- C. Apply a cold compress
- D. Elevate the limb
Correct answer: B
Rationale: When a client presents with symptoms of phlebitis at the IV site, such as redness, warmth, and pain, it is essential to discontinue the IV line. Increasing the IV flow rate could exacerbate the condition by further irritating the vein. Applying a cold compress may provide temporary relief but does not address the underlying issue of phlebitis. Elevating the limb is not the primary intervention for phlebitis and discontinuing the IV line takes precedence to prevent complications.
2. A client with liver cirrhosis is experiencing confusion. Which of the following laboratory values should the nurse report to the provider?
- A. Bilirubin 0.8 mg/dL
- B. Ammonia 145 mcg/dL
- C. Albumin 4 g/dL
- D. Hemoglobin 13.5 g/dL
Correct answer: B
Rationale: The correct answer is B: Ammonia 145 mcg/dL. An elevated ammonia level can indicate hepatic encephalopathy in clients with liver cirrhosis, leading to confusion. Bilirubin (Choice A) is within the normal range, indicating adequate liver function. Albumin (Choice C) and Hemoglobin (Choice D) levels are also within normal limits and are not directly related to the client's confusion in this scenario.
3. Sergio is brought to Emergency Room after the barbecue grill accident. Based on the assessment of the physician, Sergio sustained superficial partial thickness burns on his trunk, right upper extremities and right lower extremities. His wife asks what that means? Your most accurate response would be:
- A. Structures beneath the skin are damage
- B. Dermis is partially damaged
- C. Epidermis and dermis are both damaged
- D. Epidermis is damaged
Correct answer: B
Rationale: Nursing interventions should be grounded in a deep understanding of the physiological processes involved, ensuring that care provided is both effective and efficient.
4. Typical parents give their sons toys that emphasize __________.
- A. cooperation
- B. nurturance
- C. competition
- D. physical attractiveness
Correct answer: C
Rationale: The correct answer is C: 'competition.' Parents often give boys toys that promote competition and physical activity, aligning with traditional gender roles. This emphasis on competition can help boys develop skills such as leadership, strategy, and resilience. Choice A, 'cooperation,' is incorrect because while cooperation is valuable, it is not typically emphasized through toys given to boys. Choice B, 'nurturance,' is also incorrect as nurturing qualities are not commonly associated with toys given to boys. Choice D, 'physical attractiveness,' is unrelated to the toys parents usually give their sons.
5. A patient has just undergone a tracheostomy. What is the nurse's priority intervention?
- A. Suction the tracheostomy to maintain a patent airway.
- B. Administer pain medication as prescribed.
- C. Change the tracheostomy dressing every 4 hours.
- D. Monitor the patient's oxygen saturation closely.
Correct answer: A
Rationale: The correct answer is to suction the tracheostomy to maintain a patent airway. After a tracheostomy, the priority intervention is to ensure a clear airway to prevent respiratory distress. Administering pain medication, changing the tracheostomy dressing, and monitoring oxygen saturation are important but are secondary to maintaining a patent airway in a patient who has just undergone a tracheostomy.
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