ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?
- A. Bladder spasms
- B. Bladder distention
- C. Frequent urination
- D. Hematuria
Correct answer: B
Rationale: The correct answer is B: Bladder distention. Bladder distention is a sign of catheter occlusion because it indicates a failure to drain urine properly. Bladder spasms (Choice A) are more commonly associated with bladder irritability rather than catheter occlusion. Frequent urination (Choice C) is unlikely in a client with an indwelling catheter as the urine should be draining continuously. Hematuria (Choice D) refers to blood in the urine and is not typically a direct sign of catheter occlusion.
2. A client is in the emergency room in critical condition and hypotensive. Her spouse is distraught. What is the priority nursing action?
- A. Maintain the client’s blood pressure
- B. Call a chaplain
- C. Provide the spouse a chair
- D. Ask the client’s spouse to explain what happened
Correct answer: Maintain the client’s blood pressure
Rationale:
3. A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?
- A. I would like to play wheelchair basketball. When I get stronger, I think I'll look for a league.
- B. I'm glad I'll only be in this wheelchair temporarily. I can't wait to get back to running.
- C. I'm so upset that this happened to me. What did I do to deserve this?
- D. I feel like I'll never be able to do anything that I want to again. All I am is a burden to my family.
Correct answer: A
Rationale: Choice A is the correct answer because it shows that the client has accepted their disability and is looking towards the future with realistic goals. This positive attitude and focus on engaging in activities that are achievable despite the disability indicate effective coping mechanisms. Choice B is incorrect as it reflects denial of the permanent nature of the disability. Choice C is incorrect as it shows feelings of anger and possible self-blame, which are not indicative of effective coping. Choice D is incorrect as it demonstrates a sense of hopelessness and self-perceived burden, which are signs of maladaptive coping.
4. When providing teaching for a child prescribed ferrous sulfate, which of the following instructions should the nurse include?
- A. Take with meals
- B. Take at bedtime
- C. Take with a glass of milk
- D. Take with a glass of orange juice
Correct answer: D
Rationale: The correct answer is D, 'Take with a glass of orange juice.' Ferrous sulfate is best absorbed with vitamin C, making orange juice the preferred choice. Choices A, B, and C are incorrect because taking ferrous sulfate with meals, at bedtime, or with milk can reduce its absorption due to interactions with food components like calcium, inhibiting the iron absorption process.
5. The only IV fluid compatible with blood products is:
- A. D5LR C. NSS
- B. D5NSS D. Plain LR
- C.
- D.
Correct answer: D
Rationale: Understanding the underlying pathology and therapeutic techniques ensures that nursing care is not only reactive but also preventative, reducing the risk of complications.
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