ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is caring for a client who is postop following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased fiber intake
- B. Decreased physical activity
- C. Frequent urge suppression
- D. Adequate sleep
Correct answer: B
Rationale: The correct answer is B: Decreased physical activity. Following abdominal surgery, reduced physical activity can contribute to constipation due to decreased bowel motility. Increased fiber intake (choice A) generally helps prevent constipation by adding bulk to the stool. Frequent urge suppression (choice C) may lead to issues like urinary retention but is not directly linked to constipation. Adequate sleep (choice D) is important for overall recovery but does not significantly impact constipation risk.
2. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What is the nurse's priority action?
- A. Flush the IV line with saline
- B. Discontinue the infusion
- C. Elevate the limb
- D. Apply a cold compress
Correct answer: B
Rationale: The correct answer is to discontinue the infusion. The symptoms described - pain, redness, and warmth along the vein - are indicative of phlebitis, which is inflammation of the vein. Continuing the infusion can lead to further complications. Flushing the IV line, elevating the limb, or applying a cold compress do not address the underlying issue of phlebitis and may not be sufficient to resolve the problem. Therefore, the priority action is to discontinue the infusion to prevent worsening of the condition.
3. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. What should the nurse do to prevent contamination?
- A. Wear non-sterile gloves
- B. Apply sterile gloves over non-sterile gloves
- C. Change gloves if the sterile solution splashes onto the sterile field
- D. Cover the sterile field with a sterile drape
Correct answer: C
Rationale: The correct answer is C. If sterile solution splashes onto the sterile field, it is considered contaminated. Changing gloves in this situation ensures that the sterility of the dressing change is maintained. Choice A is incorrect as non-sterile gloves would introduce contaminants. Choice B is incorrect as layering gloves can increase the risk of contamination. Choice D is incorrect as covering the sterile field with a sterile drape is not the appropriate action to take in response to contamination.
4. A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased physical activity
- B. Frequent urge suppression
- C. Increased fiber intake
- D. Decreased fluid intake
Correct answer: B
Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt normal bowel movements and result in constipation. Increased physical activity, increased fiber intake, and adequate fluid intake are measures that typically help prevent constipation by promoting bowel regularity and preventing stool hardening. Therefore, choices A, C, and D are not behaviors that increase the client's risk for constipation.
5. A nurse is planning a community education program about colorectal cancer. What risk factors should the nurse identify as modifiable?
- A. Age and gender
- B. High-fat diet, smoking, alcohol consumption
- C. Ethnicity and race
- D. Exposure to radiation
Correct answer: B
Rationale: The correct answer is B: High-fat diet, smoking, alcohol consumption. These are modifiable risk factors for colorectal cancer as individuals can make lifestyle changes to reduce their risk. Age and gender (choice A) are non-modifiable risk factors. Ethnicity and race (choice C) can influence the risk of colorectal cancer but are not modifiable factors. Exposure to radiation (choice D) is not a common modifiable risk factor for colorectal cancer.
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