ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?
- A. Apply a heating pad to the wound
- B. Apply a moisture-retentive dressing
- C. Provide daily wound irrigation
- D. Apply an ice pack to the wound
Correct answer: B
Rationale: The correct answer is to apply a moisture-retentive dressing. This type of dressing promotes a moist wound environment, which is crucial for wound healing. Applying a heating pad can lead to tissue damage, while daily wound irrigation can disrupt the wound healing process. Applying an ice pack is not recommended for promoting wound healing in this scenario.
2. A client with chronic obstructive pulmonary disease (COPD) is being taught breathing exercises by a nurse. What instruction should the nurse include to improve oxygenation?
- A. Use pursed-lip breathing during activities
- B. Use deep breathing exercises after meals
- C. Perform diaphragmatic breathing during exercise
- D. Breathe in short, shallow breaths
Correct answer: A
Rationale: The correct instruction the nurse should include to improve oxygenation for a client with COPD is to 'Use pursed-lip breathing during activities.' Pursed-lip breathing helps improve oxygenation by slowing down the respiratory rate, reducing the work of breathing, and keeping the airways open. This technique also helps prevent the collapse of small airways during exhalation, allowing for more complete emptying of the lungs. Choices B, C, and D are incorrect because deep breathing exercises after meals, diaphragmatic breathing during exercise, and breathing in short, shallow breaths do not specifically target the improvement of oxygenation in individuals with COPD.
3. A client who is postoperative following abdominal surgery is at risk for constipation due to which behavior?
- A. Increased fiber intake
- B. Decreased fluid intake
- C. Frequent urge suppression
- D. Increased physical activity
Correct answer: B
Rationale: Postoperative clients are at risk for constipation due to various factors, including decreased fluid intake. Insufficient fluid consumption can lead to hardening of stools, making them difficult to pass. Increased fiber intake (choice A) is actually beneficial for preventing constipation as it adds bulk to the stool. Frequent urge suppression (choice C) can contribute to constipation by disrupting normal bowel habits. Increased physical activity (choice D) generally helps promote bowel movements and reduce the risk of constipation.
4. A client is being taught how to use a cane. Which instruction should the nurse include?
- A. Use the cane on the stronger side
- B. Use the cane on the weaker side
- C. Ensure the cane has a rubber tip
- D. Hold the cane 1-2 inches from the ground
Correct answer: A
Rationale: The correct answer is to use the cane on the stronger side. This instruction is important because it provides better support and balance. Placing the cane on the stronger side helps to shift weight off the weaker or injured side, reducing the risk of falls and promoting stability. Choices B, C, and D are incorrect. Using the cane on the weaker side would not provide optimal support. While ensuring the cane has a rubber tip and holding it 1-2 inches from the ground are important, they are not as crucial as using the cane on the stronger side for proper support and balance.
5. A nurse is performing a focused assessment on a client with a history of chronic obstructive pulmonary disease (COPD). What finding should the nurse expect?
- A. Increased breath sounds
- B. Flushed skin
- C. Nasal flaring
- D. Decreased respiratory rate
Correct answer: B
Rationale: The correct answer is B: Flushed skin. Flushed skin is a common finding in clients with COPD who are experiencing dyspnea. Increased breath sounds (choice A) are not typically associated with COPD; they may indicate conditions like pneumonia. Nasal flaring (choice C) is more commonly seen in respiratory distress in pediatric patients. Decreased respiratory rate (choice D) is not a typical finding in COPD and could indicate respiratory depression.
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