ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A client with a new diagnosis of diabetes mellitus needs instruction on foot care. What advice should the nurse provide?
- A. Soak feet in warm water daily
- B. Wear shoes at all times
- C. Cut toenails in a rounded shape
- D. Inspect the feet weekly
Correct answer: B
Rationale: The correct answer is B: 'Wear shoes at all times.' This instruction is crucial for clients with diabetes as it helps protect the feet from potential injuries. Choice A of soaking feet in warm water daily can lead to skin issues and should be avoided. Cutting toenails in a rounded shape, as mentioned in choice C, can increase the risk of ingrown toenails. While inspecting the feet weekly, as in choice D, is important, wearing shoes at all times is a more preventative measure to avoid foot injuries in diabetic clients.
2. A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skill should the nurse expect?
- A. Jumps with both feet
- B. Runs with coordination
- C. Walks without assistance
- D. Kicks a ball forward
Correct answer: C
Rationale: At 15 months, a toddler should be able to walk without assistance. Walking without assistance is a major gross motor skill milestone at this age, indicating the child's physical development and coordination. Choices A, B, and D are developmentally inappropriate for a 15-month-old. Jumping with both feet, running with coordination, and kicking a ball forward typically develop later in a child's growth and are more advanced skills compared to walking independently.
3. A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?
- A. Reposition the client every 4 hours
- B. Apply a moisture-retentive dressing
- C. Apply a heating pad to the site
- D. Keep the client on bedrest
Correct answer: B
Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.
4. A nurse is preparing to administer medications to a client through a nasogastric (NG) tube. Which action should the nurse take?
- A. Crush all the medications and mix them together in water
- B. Flush the NG tube with 10 mL of air before each medication
- C. Dissolve each medication separately and flush with water between medications
- D. Administer all medications at the same time
Correct answer: C
Rationale: The correct action for the nurse to take when administering medications through an NG tube is to dissolve each medication separately and flush with water between medications. This practice helps prevent interactions between medications and ensures that each medication is delivered effectively. Option A is incorrect as mixing all medications together can lead to chemical interactions or alter the effectiveness of the medications. Option B is incorrect because flushing the NG tube with air is not recommended and may cause harm. Option D is incorrect as administering all medications at the same time does not allow for proper absorption and interaction control.
5. A nurse is reviewing the medical records of a group of older adult clients. Which risk factor should the nurse identify as placing older adults at an increased risk for infections?
- A. Improved nutritional status
- B. Increased mobility
- C. Chronic conditions
- D. Lowered immune function
Correct answer: D
Rationale: The correct answer is D: Lowered immune function. Older adults often experience a decline in immune function as they age, making them more vulnerable to infections. This weakened immune system can result in increased susceptibility to various pathogens. Choice A, 'Improved nutritional status,' is incorrect because good nutrition can actually help support the immune system. Choice B, 'Increased mobility,' is not directly related to an increased risk of infections. Choice C, 'Chronic conditions,' while they can contribute to a weakened immune system, do not directly address the primary risk factor for infections in older adults.
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