ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. 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.
2. A home health nurse is teaching about chest physiotherapy (CPT) treatments to a client with COPD. Which of the following client statements should the nurse identify as an indication that the teaching has been understood?
- A. My coughing will decrease during CPT treatments.
- B. CPT treatments will decrease my respiratory infections.
- C. I will perform postural drainage after eating meals.
- D. CPT treatments will help cure my COPD.
Correct answer: B
Rationale: The correct answer is B because chest physiotherapy (CPT) helps reduce respiratory infections by loosening mucus in the lungs. Choice A is incorrect because coughing may temporarily increase during CPT treatments as mucus is being cleared. Choice C is incorrect because postural drainage is typically performed before meals. Choice D is incorrect because while CPT can help manage symptoms and improve lung function in COPD, it does not cure the disease.
3. The parent of a 1-month-old infant voices concern about the infant’s respirations. The parent states the respirations are rapid and irregular. Which information should the nurse provide?
- A. The normal respiratory rate for an infant at this age is between 20 and 30 breaths per minute.
- B. The respirations of a 1-month-old infant are normally irregular and periodically pause.
- C. An infant at this age should have regular respirations.
- D. The irregularity of the infant's respirations is concerning; I will notify the health care provider.
Correct answer: B
Rationale: The correct answer is B. Irregular respirations with periodic pauses are normal in a 1-month-old infant. Choice A is incorrect because the normal respiratory rate for an infant at this age is higher than the range provided. Choice C is incorrect as irregular respirations are expected in infants. Choice D is not appropriate as irregular respirations with periodic pauses are a normal finding in young infants and do not necessarily indicate a concern that requires immediate notification of the healthcare provider.
4. The appropriate order of steps in active management of the third stage of labor include:
- A. Cord clamping and cutting, controlled cord traction, ergometrine administration, and inspection to be sure the placenta is intact.
- B. Intravenous oxytocin, cord clamping and cutting, and fundal massage
- C. Intramuscular injection oxytocin, controlled cord traction with counter traction to the uterus, uterine massage
- D. Controlled cord traction, fundal massage and oxytocin
Correct answer: C
Rationale: Intramuscular injection of oxytocin, controlled cord traction with counter traction to the uterus, and uterine massage are the appropriate steps in active management of the third stage of labor.
5. How should signs of infection in a post-surgical patient be assessed?
- A. Check the surgical site
- B. Check the patient's vital signs
- C. Monitor for fever
- D. Check for abnormal breath sounds
Correct answer: A
Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.
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