ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. 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.
2. A nurse is planning to teach a group of older adults about the prevention of osteoporosis. What information should the nurse include in the teaching?
- A. Increase intake of vitamin C
- B. Avoid weight-bearing exercises
- C. Perform weight-bearing exercises
- D. Limit sun exposure
Correct answer: C
Rationale: The correct answer is C: Perform weight-bearing exercises. Weight-bearing exercises help maintain bone density and reduce the risk of osteoporosis in older adults. Choice A, increasing intake of vitamin C, is not directly related to osteoporosis prevention. Choice B, avoiding weight-bearing exercises, is incorrect as weight-bearing exercises are beneficial for bone health. Choice D, limiting sun exposure, is not a key factor in osteoporosis prevention as moderate sun exposure is important for vitamin D synthesis which is essential for bone health.
3. A healthcare professional is reviewing the health history of a client who has a hip fracture. What is a risk factor for developing pressure injuries?
- A. Increased fluid intake
- B. Urinary incontinence
- C. Poor nutrition
- D. Immobility
Correct answer: B
Rationale: Urinary incontinence is a risk factor for developing pressure injuries as it can lead to skin breakdown due to constant exposure to moisture and irritation. Increased fluid intake is important for hydration and overall health but is not directly linked to pressure injuries. Poor nutrition can impair wound healing but is not a direct risk factor for pressure injuries. Immobility can contribute to the development of pressure injuries but is not as directly related as urinary incontinence.
4. A nurse is preparing to perform a focused respiratory assessment on a client with COPD. What is an expected finding?
- A. Normal respiratory rate
- B. Nasal flaring
- C. Decreased breath sounds
- D. Increased breath sounds
Correct answer: B
Rationale: Nasal flaring is an expected finding in clients with COPD who are experiencing respiratory distress. Nasal flaring is a sign of increased work of breathing and respiratory distress, commonly seen in clients with COPD exacerbation. Choices A, C, and D are incorrect. A normal respiratory rate would not be an expected finding in a client with COPD, as they often have an increased respiratory rate. Decreased breath sounds could indicate diminished airflow but are not typically a common finding in COPD. Increased breath sounds are not typical in COPD and could indicate other conditions like pneumonia.
5. During a focused assessment for a client with dysrhythmias, what indicates ineffective cardiac contractions?
- A. Increased heart rate
- B. Pulse deficit
- C. Elevated blood pressure
- D. Bounding pulse
Correct answer: B
Rationale: A pulse deficit is a crucial finding in clients with dysrhythmias as it indicates ineffective cardiac contractions. A pulse deficit occurs when the apical heart rate is faster than the radial pulse rate, suggesting that some heartbeats are not generating a pulse. This can be a sign of serious heart conditions like atrial fibrillation or heart failure. The other options, such as an increased heart rate (choice A), elevated blood pressure (choice C), and bounding pulse (choice D), do not specifically indicate ineffective cardiac contractions and are not directly associated with dysrhythmias.
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