ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. What action should the nurse take?
- A. Dissolve crushed tablet medications in tap water
- B. Administer all medications together
- C. Flush the NG tube with 60 mL of water before each medication
- D. Dissolve medications separately and flush with sterile water
Correct answer: D
Rationale: The correct action for the nurse to take when administering medications through a nasogastric (NG) tube is to dissolve medications separately and flush the tube with sterile water. This is important to prevent interactions between medications and ensure accurate administration. Option A is incorrect because tap water may not be sterile and could lead to contamination. Option B is incorrect as it increases the risk of drug interactions and may affect the effectiveness of each medication. Option C is incorrect as 60 mL of water before each medication may not be enough to ensure proper medication delivery and prevent interactions.
2. A nurse receives a report from assistive personnel that a client's BP is 160/95. What should the nurse do first?
- A. Notify the provider
- B. Recheck the blood pressure
- C. Administer antihypertensive medication
- D. Document the blood pressure in the chart
Correct answer: B
Rationale: The correct first action for the nurse to take when receiving a report of a client's blood pressure reading of 160/95 is to recheck the blood pressure. Rechecking the blood pressure ensures the accuracy of the reading before making any further decisions or interventions. Notifying the provider (Choice A) can be considered after confirming the blood pressure reading. Administering antihypertensive medication (Choice C) should not be done based solely on one reading without verification. Documenting the blood pressure in the chart (Choice D) should also come after confirming the accuracy of the reading to avoid recording incorrect information.
3. A healthcare professional is reviewing the lab results of a client who has been experiencing a fever for 3 days. What finding indicates fluid volume deficit (FVD)?
- A. Decreased hematocrit
- B. Increased white blood cell count
- C. Increased hematocrit
- D. Decreased white blood cell count
Correct answer: C
Rationale: Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. In FVD, there is a loss of fluid without a proportional loss of electrolytes, leading to hemoconcentration. Choices A, B, and D are incorrect. Decreased hematocrit and decreased white blood cell count are not typical findings in fluid volume deficit. An increased white blood cell count is more indicative of infection or inflammation rather than fluid volume deficit.
4. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?
- A. Nutritional status
- B. Client's response to pain medication
- C. Daily vital signs
- D. Most recent lab results
Correct answer: B
Rationale: The correct answer is B: Client's response to pain medication. When transferring a client to another unit, it is crucial to communicate how the client is responding to pain medication to ensure continuity of care and appropriate pain management. While nutritional status, daily vital signs, and most recent lab results are important aspects of the client's care, the client's response to pain medication directly impacts their comfort and well-being during the transfer process.
5. A nurse is providing discharge teaching for a client with chronic obstructive pulmonary disease (COPD). What instruction should the nurse include to help improve oxygenation?
- A. Use pursed-lip breathing during activities
- B. Avoid physical activity
- C. Perform weight-bearing exercises
- D. Use a humidifier while sleeping
Correct answer: A
Rationale: Corrected Rationale: The nurse should instruct the client to use pursed-lip breathing during activities to help improve oxygenation. Pursed-lip breathing can keep the airways open longer, facilitating better oxygen exchange and making it easier to exhale carbon dioxide. Choice B is incorrect as physical activity, within the client's limitations, is beneficial for maintaining overall health. Choice C is incorrect as weight-bearing exercises are important for bone health but not directly related to improving oxygenation in COPD. Choice D is incorrect as using a humidifier while sleeping can help with moisture in the airways but does not directly impact oxygenation in COPD.
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