ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. 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.
2. A nurse provides instructions to a client about preventing injury while using crutches. What should the nurse tell the client to avoid?
- A. An abnormal stance
- B. Injury to the nerves
- C. A fall and further injury
- D. Skin breakdown
Correct answer: B
Rationale: The correct answer is B: Injury to the nerves. Resting the underside of the arm on the crutch pad can injure the nerves. Choice A, an abnormal stance, is not directly related to nerve injury while using crutches. Choice C, a fall and further injury, is a general risk associated with improper crutch use but does not specifically address nerve injury. Choice D, skin breakdown, is a concern related to pressure ulcers but not the primary focus when discussing injury prevention related to crutch use.
3. Which client is at highest risk of compromised immunity?
- A. A client who just had surgery
- B. A client who just delivered a baby
- C. A client with extreme anxiety
- D. A client who is awaiting surgery
Correct answer: A client who just had surgery
Rationale:
4. The client diagnosed with Type 2 diabetes mellitus is being taught about diet by the nurse. Which diet selection indicates the client understands the teaching?
- A. A submarine sandwich, potato chips, and diet cola
- B. Four (4) slices of a supreme thin-crust pizza and milk
- C. Smoked turkey sandwich, celery sticks, and unsweetened tea
- D. A roast beef sandwich, fried onion rings, and a cola
Correct answer: C
Rationale: The correct answer is C because a smoked turkey sandwich with celery sticks and unsweetened tea reflects a balanced and healthy choice suitable for a client with Type 2 diabetes mellitus. Turkey is a lean protein choice, celery sticks offer fiber and low calories, and unsweetened tea is a sugar-free beverage. Choices A, B, and D are incorrect as they include high-carb, high-fat, and sugary options that are not recommended for individuals with diabetes as they can spike blood sugar levels.
5. When providing mouth care to an unconscious client, what is the best position for the client?
- A. Fowler’s position
- B. Side-lying
- C. Supine
- D. Trendelenburg
Correct answer: B
Rationale: The best position for an unconscious client when providing mouth care is the side-lying position. This position helps prevent aspiration by allowing fluids to drain out of the mouth easily, reducing the risk of choking or aspiration pneumonia. Placing the client in a side-lying position also promotes comfort and safety during the procedure. The other options are not ideal for mouth care in an unconscious client: Fowler’s position may increase the risk of aspiration, the supine position can lead to aspiration as well, and Trendelenburg position is not recommended due to potential adverse effects on blood circulation and increased intracranial pressure.
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