a nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter what is the nurses first action a nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter what is the nurses first action
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Nursing Elites

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ATI Capstone Fundamentals Assessment Proctored

1. A nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter. What is the nurse's first action?

Correct answer: B

Rationale: The correct first action for the nurse to take when a client reports pain and tenderness at the site of an indwelling urinary catheter is to notify the provider. Pain and tenderness at the catheter site may indicate infection, and the healthcare provider needs to be informed for further assessment and appropriate interventions. Irrigating the catheter with normal saline (Choice A) should not be the initial action without consulting the provider first. While assessing for signs of infection (Choice C) is important, notifying the provider takes precedence. Administering prescribed antibiotics (Choice D) should only be done based on the provider's orders after assessment and confirmation of infection.

2. A nurse manager is using the nominal group technique to gather input from the staff on a new policy. What is the primary method of exchange in this technique?

Correct answer: C

Rationale: In the nominal group technique, the primary method of exchange is through written reports. Participants independently generate ideas in writing, which are then shared and discussed within the group. This structured process allows for equal participation and prevents dominant individuals from influencing the group's outcome. Oral presentations (choice A) involve speaking rather than written communication, making it less suitable for the nominal group technique. Email exchanges (choice B) are also not the primary method as they lack the structured approach of the nominal group technique. Group discussions (choice D) do occur in the nominal group technique but are secondary to the initial written idea generation phase.

3. Dr. Smythe believes that in order to fully understand complex processes, such as taste, it is necessary to understand the purpose that taste plays in survival, not the elementary components that combine to produce taste sensations. Dr. Smythe's views are most consistent with?

Correct answer: B

Rationale: Dr. Smythe's belief that understanding the purpose of taste in survival is more critical than focusing on the elementary components aligns with the functionalist approach to psychology. Functionalism emphasizes understanding the purpose or function of mental processes and behavior, rather than just analyzing their individual components. This approach looks at how mental processes help individuals adapt to their environment and survive. Therefore, choices A, C, and D are incorrect because they do not prioritize understanding the purpose of mental processes and behavior in the context of survival.

4. A client had an inferior wall myocardial infarction (MI). The nurse notes the client's cardiac rhythm as shown below. What action by the nurse is most important?

Correct answer: A

Rationale: The ECG strip shows sinus bradycardia, which is common in clients with an inferior wall MI. This rhythm can lead to decreased perfusion due to bradycardia and blocks. The most crucial initial action for the nurse is to assess the client's hemodynamic status, including blood pressure and level of consciousness. This assessment will help determine the immediate needs of the client. Calling the health care provider or the Rapid Response Team, obtaining a permit for a pacemaker insertion, or preparing to administer antidysrhythmic medication may be necessary based on the assessment findings, but the priority is to evaluate the client's current condition first.

5. How many diet-related major risk factors for coronary heart disease does Mrs. Winslow have?

Correct answer: B

Rationale: Mrs. Winslow has four major diet-related risk factors for coronary heart disease: high total cholesterol, high LDL cholesterol, high triglycerides, and low HDL cholesterol. Choice A is incorrect because there are more than one risk factor present. Choices C and D are incorrect as they do not account for the total number of diet-related major risk factors identified.

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