ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?
- A. Palpate the abdomen before auscultation
- B. Inspect the abdomen after palpation
- C. Auscultate before palpation
- D. Start by percussing the abdomen
Correct answer: C
Rationale: The correct answer is to auscultate before palpation when performing an abdominal assessment. This sequence is crucial to prevent altering bowel sounds. Starting with palpation (Choice A) can lead to false interpretations of bowel sounds due to stimulation of the intestines. Inspecting the abdomen after palpation (Choice B) can also potentially alter the assessment findings. Starting with percussion (Choice D) is not recommended as it should come after auscultation to further assess underlying structures.
2. Why are anatomy and physiology difficult to separate?
- A. Physiological functions depend on anatomical structures.
- B. Physiological functions in an organism are ongoing.
- C. Body parts provide structural support.
- D. Our understanding of physiology is changing more than our understanding of anatomy.
Correct answer: Physiological functions depend on anatomical structures.
Rationale: Anatomy and physiology are difficult to separate because physiological functions depend on anatomical structures. The correct answer highlights the interdependence between the two disciplines; physiological functions are carried out by anatomical structures. Choice B is incorrect as it only states a characteristic of physiological functions without addressing the relationship with anatomy. Choice C is incorrect as it talks about body parts providing structural support, which is not directly related to the interdependence of anatomy and physiology. Choice D is incorrect because the rate of change in understanding does not necessarily dictate the difficulty of separating the two disciplines.
3. A school-age child is admitted to the pediatric unit with a vaso-occlusive crisis. Which of these should be included in the nursing plan of care?
- A. Correction of alkalosis
- B. Pain management and administration of heparin
- C. Adequate oxygenation and replacement of factor VIII to correct the sickling
- D. Adequate hydration, oxygenation, and pain management
Correct answer: D
Rationale: The correct answer is D. Vaso-occlusive crises in sickle cell anemia require a comprehensive approach that includes adequate hydration to reduce blood viscosity, oxygenation to prevent further sickling of red blood cells, and aggressive pain management. This approach helps improve tissue perfusion and manage pain effectively. Choices A, B, and C are incorrect. Correction of alkalosis is not a priority in vaso-occlusive crisis management. Administration of heparin is not indicated as it can increase the risk of bleeding in sickle cell patients. Factor VIII replacement is not relevant to sickle cell anemia as it is a treatment for hemophilia, not sickle cell disease.
4. The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client’s neurological status should include which of the following? (Select all that apply)
- A. Obtain the pulses in all four extremities
- B. Ask the client to grasp and squeeze two fingers on each of the nurse’s hands
- C. Determine the client’s orientation to person, place, and time
- D. B, C
Correct answer: D
Rationale: The correct choices are B and C. Assessing grasp strength and orientation to person, place, and time are essential components of a neurological assessment after a CVA. Pulse assessment in all four extremities is more relevant to circulatory assessment rather than neurological status. Therefore, option A is incorrect.
5. The breakdown in teamwork is often times a failure in:
- A. Electricity
- B. Inadequate supply
- C. Leg work
- D. Communication
Correct answer: A
Rationale: Patient safety and efficacy of care depend on actions rooted in established nursing protocols that consider both the immediate and long-term needs of the patient.
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