ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. What should the nurse do to prevent contamination?
- A. Wear non-sterile gloves
- B. Apply sterile gloves over non-sterile gloves
- C. Change gloves if the sterile solution splashes onto the sterile field
- D. Cover the sterile field with a sterile drape
Correct answer: C
Rationale: The correct answer is C. If sterile solution splashes onto the sterile field, it is considered contaminated. Changing gloves in this situation ensures that the sterility of the dressing change is maintained. Choice A is incorrect as non-sterile gloves would introduce contaminants. Choice B is incorrect as layering gloves can increase the risk of contamination. Choice D is incorrect as covering the sterile field with a sterile drape is not the appropriate action to take in response to contamination.
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 is providing discharge teaching to a client with a new diagnosis of hypertension. What instruction should the nurse include?
- A. Reduce sodium intake to 4 grams per day
- B. Avoid foods high in potassium
- C. Take prescribed antihypertensive medications daily
- D. Limit fluid intake to 1 liter per day
Correct answer: C
Rationale: The correct answer is C: 'Take prescribed antihypertensive medications daily.' When providing discharge teaching to a client with hypertension, one of the key instructions is to ensure the consistent intake of prescribed antihypertensive medications. This is crucial for controlling blood pressure levels and reducing the risk of complications associated with hypertension. Choices A, B, and D are incorrect because reducing sodium intake, avoiding foods high in potassium, and limiting fluid intake are important dietary modifications for various health conditions, but they are not the priority when it comes to managing hypertension. The primary focus should be on medication adherence to effectively manage hypertension.
4. A healthcare professional is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the professional include?
- A. Inhale for 1 second
- B. Shake the inhaler vigorously
- C. Hold the inhaler 5-7 cm away from the mouth
- D. Hold breath for 5 seconds after inhalation
Correct answer: B
Rationale: The correct instruction when using a metered-dose inhaler (MDI) is to shake the inhaler vigorously before use. Shaking the inhaler ensures proper mixing of the medication, which is crucial for effective delivery of the medication into the lungs. Inhaling for a specific duration, holding the inhaler at a certain distance from the mouth, or holding the breath after inhalation are not as critical as ensuring proper mixing of the medication by shaking the inhaler.
5. A healthcare professional is reviewing the medical record of a client with a hip fracture. Which finding is a risk factor for pressure injuries?
- A. Frequent repositioning
- B. Poor nutrition
- C. Use of a special mattress
- D. Urinary incontinence
Correct answer: C
Rationale: The correct answer is the use of a special mattress. Special mattresses are designed to reduce pressure on bony prominences, thereby helping to prevent pressure injuries. Frequent repositioning (Choice A) is actually a preventive measure for pressure injuries. Poor nutrition (Choice B) can contribute to delayed wound healing but is not a direct risk factor for pressure injuries. Urinary incontinence (Choice D) can increase the risk of skin breakdown but is not a direct risk factor for pressure injuries.
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