ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A healthcare professional is preparing to administer an intramuscular injection to a client. What is the appropriate site for the injection to avoid injury?
- A. Deltoid
- B. Ventrogluteal
- C. Rectus femoris
- D. Dorsogluteal
Correct answer: B
Rationale: The ventrogluteal site is the preferred site for intramuscular injections to avoid injury to nerves or blood vessels. The deltoid site is commonly used for vaccines but has a higher risk of hitting the radial nerve. The rectus femoris site is not typically recommended for intramuscular injections. The dorsogluteal site is contraindicated due to the proximity to the sciatic nerve and major blood vessels.
2. A nurse is providing discharge teaching to a client with a prescription for home oxygen therapy. What information should the nurse include?
- A. Increase the oxygen flow rate when shortness of breath occurs
- B. Turn off the oxygen when not in use
- C. Avoid open flames or smoking near oxygen
- D. Store the oxygen tubing near heat sources
Correct answer: C
Rationale: The correct answer is C: 'Avoid open flames or smoking near oxygen.' This information is crucial to prevent fire hazards as oxygen supports combustion. Choices A, B, and D are incorrect. Increasing the oxygen flow rate without healthcare provider's instructions can be dangerous. Oxygen should not be turned off when not in use as prescribed by the healthcare provider, and storing oxygen tubing near heat sources poses a risk of fire.
3. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?
- A. Administer antihypertensive medication
- B. Notify the healthcare provider
- C. Recheck the blood pressure
- D. Document the blood pressure in the chart
Correct answer: C
Rationale: The correct first action for the nurse in this scenario is to recheck the blood pressure. This step is crucial to confirm the accuracy of the initial reading. Administering antihypertensive medication without verifying the blood pressure could lead to inappropriate treatment. Notifying the healthcare provider can be done after ensuring the accuracy of the reading. Simply documenting the blood pressure without validation may result in acting on potentially incorrect information. Therefore, the priority is to recheck the blood pressure.
4. A client with diabetes mellitus is being taught about foot care by a nurse. Which instruction should the nurse include?
- A. Cut toenails straight across
- B. Wear shoes at all times
- C. Apply lotion between the toes
- D. Soak feet in hot water daily
Correct answer: B
Rationale: The correct answer is to 'Wear shoes at all times.' This instruction is crucial for preventing foot injuries in clients with diabetes mellitus. Wearing shoes protects the feet from potential injuries and reduces the risk of developing foot ulcers. Cutting toenails straight across (not in a rounded shape) helps prevent ingrown toenails. Applying lotion between the toes can create a moist environment, increasing the risk of fungal infections. Soaking feet in hot water daily can lead to dry skin and potentially cause burns, which is not recommended for individuals with diabetes.
5. A client is found on the floor experiencing a seizure. What is the nurse's priority action?
- A. Apply oxygen
- B. Place the client on their side
- C. Administer an anticonvulsant
- D. Notify the provider
Correct answer: B
Rationale: The nurse's priority action when finding a client experiencing a seizure is to place the client on their side. This action helps maintain an open airway and prevents aspiration, which is crucial during a seizure. Applying oxygen may be necessary after ensuring a patent airway, while administering an anticonvulsant is not within the nurse's scope of practice during an acute seizure. Notifying the provider can be done after ensuring the client's immediate safety.
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