ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is reviewing a client's health history and identifies urinary incontinence as a risk factor for pressure injuries. What should the nurse include in the plan of care?
- A. Use a heating pad for comfort
- B. Apply a barrier cream to the skin
- C. Reposition the client every 4 hours
- D. Change the client's position every 2 hours
Correct answer: C
Rationale: The correct answer is to reposition the client every 4 hours. Repositioning the client helps prevent pressure injuries caused by urinary incontinence by relieving pressure on vulnerable areas of the skin. Choice A, using a heating pad for comfort, is not directly related to preventing pressure injuries. Choice B, applying a barrier cream to the skin, may help protect the skin but does not address the underlying cause of pressure injuries. Choice D, changing the client's position every 2 hours, is more frequent than necessary and may not be as effective in preventing pressure injuries as repositioning every 4 hours.
2. Before administering lithium to a client with bipolar disorder who has been taking the medication for 1 year, the nurse should check to see that which of the following tests has been completed?
- A. Thyroid hormone assay
- B. Liver function tests
- C. Erythrocyte sedimentation rate
- D. Brain natriuretic peptide
Correct answer: A
Rationale: The correct answer is to check the thyroid hormone assay. Long-term lithium use can result in thyroid dysfunction, making it crucial to monitor the client's thyroid function regularly to detect any abnormalities early and prevent potential complications. Liver function tests (choice B) are not specifically associated with lithium therapy. Erythrocyte sedimentation rate (choice C) is a nonspecific test for inflammation and not directly related to lithium therapy. Brain natriuretic peptide (choice D) is a test used to diagnose heart failure and is not relevant to monitoring lithium therapy.
3. A nurse at a provider's office receives a phone call from a client who reports unrelieved chest pain after taking a nitroglycerin (Nitrostat) tablet 5 minutes ago. Which of the following is an appropriate response by the nurse?
- A. Tell the client to take an aspirin.
- B. Instruct the client to call 911.
- C. Have the client take another nitroglycerin tablet in 15 minutes.
- D. Advise the client to come to the office.
Correct answer: Instruct the client to call 911.
Rationale: In this scenario, the client reporting unrelieved chest pain after taking a nitroglycerin tablet could be indicative of a serious cardiac event. Instructing the client to call 911 is the most appropriate response because immediate medical attention is necessary for chest pain that is not relieved by nitroglycerin. Telling the client to take an aspirin (Choice A) may not address the urgency of the situation, and aspirin might not be appropriate depending on the client's medical history. Having the client take another nitroglycerin tablet (Choice C) without relief could lead to overdosage. Advising the client to come to the office (Choice D) is not the best course of action when dealing with a potential cardiac emergency that requires immediate intervention.
4. A client with obsessive-compulsive disorder (OCD) tells the nurse, 'I know my behavior is unreasonable, but I can't help it.' What response should the nurse provide?
- A. Your behavior is part of your illness, and it is important to work on changing it.
- B. It is important to understand why you feel the need to perform these behaviors.
- C. Let's figure out a way for you to control these behaviors.
- D. It sounds like you are feeling powerless to change your behavior.
Correct answer: D
Rationale: The nurse should acknowledge the client's awareness of the irrationality of their behavior and the feeling of powerlessness to change it. By reflecting the client's feelings, the nurse validates them and opens a discussion on strategies to manage the behavior effectively. Empathy and understanding are key in supporting clients with OCD. Choice A is incorrect because it focuses more on changing the behavior rather than acknowledging the client's feelings. Choice B is incorrect as it does not directly address the client's sense of powerlessness. Choice C is incorrect as it doesn't validate the client's feelings of being unable to control the behaviors.
5. A client is taking Epoetin Alfa for anemia. Which of the following laboratory tests should the nurse monitor to evaluate the effectiveness of the therapy?
- A. White blood cell count
- B. Platelet count
- C. Hematocrit
- D. Serum potassium level
Correct answer: C
Rationale: The nurse should monitor the hematocrit level to evaluate the effectiveness of Epoetin Alfa therapy. Epoetin Alfa stimulates red blood cell production, leading to an increase in hematocrit levels. Monitoring the hematocrit helps assess the response to therapy and ensures that the medication is effectively addressing the anemia. White blood cell count and platelet count are not directly affected by Epoetin Alfa therapy. Serum potassium level monitoring is important for other medications that may impact potassium levels but is not specifically relevant to assessing the effectiveness of Epoetin Alfa in treating anemia.
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