ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is providing discharge teaching to a client who has a prescription for home oxygen therapy. What should the nurse teach?
- A. Remove the oxygen tubing during meals
- B. Wear synthetic fabrics while using oxygen
- C. Use cotton fabrics when oxygen is in use
- D. Increase oxygen flow during physical activity
Correct answer: C
Rationale: The correct answer is C: 'Use cotton fabrics when oxygen is in use.' When a client is on oxygen therapy, it is essential to use cotton fabrics to reduce the risk of static electricity, which can ignite in the presence of oxygen. Choices A, B, and D are incorrect. Removing the oxygen tubing during meals is not necessary as long as proper precautions are taken to avoid tripping hazards. Synthetic fabrics should be avoided while using oxygen therapy to prevent static electricity buildup. Increasing oxygen flow during physical activity should be done according to the healthcare provider's instructions, not indiscriminately.
2. A nurse is caring for a client who is undergoing surgery for a hip fracture. What is a priority intervention to reduce the risk of postoperative complications?
- A. Encourage early ambulation
- B. Provide intravenous antibiotics
- C. Apply anti-embolism stockings
- D. Place a Foley catheter to monitor output
Correct answer: A
Rationale: Encouraging early ambulation is crucial in reducing the risk of postoperative complications, such as blood clots and pneumonia. Early mobilization helps prevent complications like deep vein thrombosis and pneumonia by promoting circulation and preventing respiratory complications. Providing intravenous antibiotics (Choice B) is important for preventing infections but is not the priority immediately post-surgery. Applying anti-embolism stockings (Choice C) is beneficial in preventing venous thromboembolism but does not address the immediate need for mobility. Placing a Foley catheter (Choice D) may be necessary during surgery but is not a priority intervention to reduce postoperative complications related to immobility.
3. A client who is postoperative following abdominal surgery is at risk for constipation due to which behavior?
- A. Increased fiber intake
- B. Decreased fluid intake
- C. Frequent urge suppression
- D. Increased physical activity
Correct answer: B
Rationale: Postoperative clients are at risk for constipation due to various factors, including decreased fluid intake. Insufficient fluid consumption can lead to hardening of stools, making them difficult to pass. Increased fiber intake (choice A) is actually beneficial for preventing constipation as it adds bulk to the stool. Frequent urge suppression (choice C) can contribute to constipation by disrupting normal bowel habits. Increased physical activity (choice D) generally helps promote bowel movements and reduce the risk of constipation.
4. A nurse is updating the plan of care for a client with limited mobility. What intervention should the nurse include to prevent skin breakdown?
- A. Reposition the client every 4 hours
- B. Apply lotion to the skin every 2 hours
- C. Use a special mattress to reduce pressure on the skin
- D. Increase fluid intake to promote skin hydration
Correct answer: C
Rationale: The correct answer is C: 'Use a special mattress to reduce pressure on the skin.' This intervention is crucial in preventing skin breakdown in clients with limited mobility as it helps to reduce pressure on bony prominences. Repositioning every 4 hours (Choice A) is important but may not be sufficient to prevent skin breakdown entirely. Applying lotion every 2 hours (Choice B) may not address the root cause of skin breakdown related to pressure. Increasing fluid intake (Choice D) is beneficial for overall skin health but may not directly prevent skin breakdown caused by pressure points.
5. A client who is at risk for developing a deep vein thrombosis (DVT) after surgery. What intervention should the nurse implement to reduce this risk?
- A. Avoid ambulation to prevent injury
- B. Use compression stockings
- C. Use a heating pad for comfort
- D. Elevate the client's legs on a pillow
Correct answer: B
Rationale: The correct intervention to reduce the risk of deep vein thrombosis (DVT) after surgery is to use compression stockings. Compression stockings help prevent DVT by promoting venous return, which reduces the likelihood of blood pooling in the legs and forming clots. Choices A, C, and D are incorrect because avoiding ambulation can actually increase the risk of DVT, using a heating pad does not directly address DVT prevention, and elevating the client's legs on a pillow alone may not provide sufficient compression to prevent DVT.
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