ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A client signed an informed consent form for surgery but has expressed doubts about the need for surgery. What should the nurse say?
- A. Reassure the client of the surgeon's skill
- B. The surgeon will answer your questions before surgery
- C. Tell the client surgery is necessary
- D. Encourage the client to seek a second opinion
Correct answer: B
Rationale: The correct answer is B because the surgeon should address the client's doubts before surgery. Informed consent requires that the client fully understands the procedure. Choice A is incorrect because reassuring the client of the surgeon's skill does not address the client's doubts about the need for surgery. Choice C is incorrect because telling the client surgery is necessary may not address their concerns and could violate the principle of autonomy. Choice D is incorrect as the immediate concern is addressing the client's doubts before surgery, not necessarily seeking a second opinion.
2. A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. What action should the nurse take?
- A. Dissolve crushed tablet medications in tap water
- B. Administer all medications together
- C. Flush the NG tube with 60 mL of water before each medication
- D. Dissolve medications separately and flush with sterile water
Correct answer: D
Rationale: The correct action for the nurse to take when administering medications through a nasogastric (NG) tube is to dissolve medications separately and flush the tube with sterile water. This is important to prevent interactions between medications and ensure accurate administration. Option A is incorrect because tap water may not be sterile and could lead to contamination. Option B is incorrect as it increases the risk of drug interactions and may affect the effectiveness of each medication. Option C is incorrect as 60 mL of water before each medication may not be enough to ensure proper medication delivery and prevent interactions.
3. 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.
4. A nurse receives a report from assistive personnel that a client's BP is 160/95. What should the nurse do first?
- A. Notify the provider
- B. Recheck the blood pressure
- C. Administer antihypertensive medication
- D. Document the blood pressure in the chart
Correct answer: B
Rationale: The correct first action for the nurse to take when receiving a report of a client's blood pressure reading of 160/95 is to recheck the blood pressure. Rechecking the blood pressure ensures the accuracy of the reading before making any further decisions or interventions. Notifying the provider (Choice A) can be considered after confirming the blood pressure reading. Administering antihypertensive medication (Choice C) should not be done based solely on one reading without verification. Documenting the blood pressure in the chart (Choice D) should also come after confirming the accuracy of the reading to avoid recording incorrect information.
5. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?
- A. Frequent repositioning
- B. Poor nutrition
- C. Increased fluid intake
- D. Use of a special mattress
Correct answer: B
Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.
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