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. Encourage a high-protein diet
- 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 promotes a moist wound environment, which is crucial for wound healing in clients with diabetes. Encouraging a high-protein diet may support overall health but is not directly related to wound healing. Daily wound irrigation can disrupt the wound healing process by removing necessary growth factors and cells. Applying an ice pack to the wound is contraindicated as it can impair circulation and delay wound healing.
2. A nurse is caring for a client who has experienced a seizure. What should the nurse do immediately after the seizure?
- A. Administer oxygen
- B. Document the seizure activity
- C. Turn the client on their side
- D. Reassure the client
Correct answer: C
Rationale: After a client experiences a seizure, the nurse should immediately turn the client on their side. This action helps maintain an open airway and prevents aspiration, as it allows any secretions or vomitus to drain from the mouth. Administering oxygen can be necessary if the client is hypoxic, but turning the client on their side takes precedence to prevent complications. While documenting the seizure activity is important for the client's medical record, ensuring the client's immediate safety by positioning them correctly is the priority. Reassuring the client should follow after ensuring their physical safety.
3. A nurse is preparing to administer a medication through a nasogastric (NG) tube. What action should the nurse take first?
- A. Flush the NG tube with 60 mL of water
- B. Verify tube placement
- C. Crush the medications and dissolve them in water
- D. Administer all medications together
Correct answer: B
Rationale: Verifying tube placement is the priority before administering any medications through a nasogastric tube. This step ensures that the tube is correctly positioned in the stomach to prevent complications such as aspiration. Flushing the tube with water, crushing medications, or administering them together should only be done after confirming the correct placement of the NG tube. Therefore, option B is the correct first action to take in this scenario.
4. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?
- A. Avoid discussing the deceased
- B. Encourage the partner to ask for help when needed
- C. Suggest bereavement counseling
- D. Offer to contact family members
Correct answer: B
Rationale: Encouraging the partner to ask for help when needed is the most appropriate action in this scenario as it promotes healthy coping mechanisms and support during the mourning process. This approach empowers the individual to seek assistance when required, fostering a sense of control and acknowledging the partner's autonomy in dealing with their grief. Avoiding discussing the deceased (Choice A) may hinder the grieving process by suppressing emotions and preventing the partner from expressing their feelings. While suggesting bereavement counseling (Choice C) is important, the immediate support and encouragement to seek help when needed are crucial. Offering to contact family members (Choice D) may not be the most effective step at this stage, as the focus should be on empowering the partner to cope and seek help on their terms.
5. A client with a new diagnosis of diabetes mellitus is being taught about foot care. What instruction should the nurse include?
- A. Apply lotion between the toes after bathing
- 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 to wear shoes at all times. This instruction is vital for clients with diabetes mellitus as it helps protect the feet and reduces the risk of injury. Option A is incorrect as applying lotion between the toes can increase moisture and the risk of fungal infections. Option C is incorrect as cutting toenails in a rounded shape may lead to ingrown toenails. Option D is also incorrect as inspecting the feet weekly is not sufficient for proper foot care in clients with diabetes mellitus.
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