ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is providing discharge instructions to a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?
- A. Steamed carrots
- B. Orange slices
- C. Mashed potatoes
- D. Baked chicken
Correct answer: B
Rationale: The correct answer is B: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices fall into this category due to their texture and potential choking hazard. Steamed carrots, mashed potatoes, and baked chicken are typically suitable for a mechanical soft diet as they can be easily mashed or cut into small, manageable pieces for consumption.
2. When teaching about safety risks for adolescents, what should the nurse emphasize?
- A. Adolescents have a decreased risk of injury
- B. Peer pressure can lead to risky behaviors
- C. Increased responsibility reduces risks
- D. Adolescents are less likely to engage in substance abuse
Correct answer: B
Rationale: The correct answer is B: 'Peer pressure can lead to risky behaviors.' Adolescents are at an increased risk for injury due to peer pressure and the tendency to engage in high-risk behaviors. Emphasizing the impact of peer pressure on decision-making can help adolescents make safer choices. Choices A, C, and D are incorrect because adolescents actually have an increased risk of injury, increased responsibility does not always reduce risks, and many adolescents are at risk of engaging in substance abuse.
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 nurse is caring for a client who has experienced a seizure. What should the nurse do immediately after the seizure?
- A. Administer oxygen
- B. Document the seizure activity
- C. Turn the client on their side
- D. Reassure the client
Correct answer: C
Rationale: After a client experiences a seizure, the nurse should immediately turn the client on their side. This action helps maintain an open airway and prevents aspiration, as it allows any secretions or vomitus to drain from the mouth. Administering oxygen can be necessary if the client is hypoxic, but turning the client on their side takes precedence to prevent complications. While documenting the seizure activity is important for the client's medical record, ensuring the client's immediate safety by positioning them correctly is the priority. Reassuring the client should follow after ensuring their physical safety.
5. When reviewing the health history of an older adult with a hip fracture, what should a nurse identify as a risk factor for developing pressure injuries?
- A. Malnutrition
- B. Poor hygiene
- C. Urinary incontinence
- D. Immobility
Correct answer: C
Rationale: Urinary incontinence is a risk factor for skin breakdown, which can lead to the development of pressure injuries. While malnutrition, poor hygiene, and immobility are important considerations in overall patient care, they are not specifically identified as significant risk factors for pressure injuries in this scenario.
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