ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is reviewing the medical records of a group of older adult clients. Which risk factor should the nurse identify as placing older adults at an increased risk for infections?
- A. Improved nutritional status
- B. Increased mobility
- C. Chronic conditions
- D. Lowered immune function
Correct answer: D
Rationale: The correct answer is D: Lowered immune function. Older adults often experience a decline in immune function as they age, making them more vulnerable to infections. This weakened immune system can result in increased susceptibility to various pathogens. Choice A, 'Improved nutritional status,' is incorrect because good nutrition can actually help support the immune system. Choice B, 'Increased mobility,' is not directly related to an increased risk of infections. Choice C, 'Chronic conditions,' while they can contribute to a weakened immune system, do not directly address the primary risk factor for infections in older adults.
2. A nurse is preparing to administer a medication to a client with a nasogastric (NG) tube. What action should the nurse take?
- A. Administer the medication with a straw
- B. Flush the NG tube with 30 mL of water before administration
- C. Crush all medications together
- D. Mix the medication with pudding
Correct answer: B
Rationale: The correct action for the nurse to take when administering medication to a client with a nasogastric (NG) tube is to flush the NG tube with 30 mL of water before administration. Flushing the tube with water helps ensure the patency of the tube and prevents clogging. Choice A is incorrect because administering the medication with a straw is not a recommended practice for NG tube administration. Choice C is incorrect because crushing all medications together may lead to potential drug interactions. Choice D is incorrect because mixing the medication with pudding is not a standard method for administering medication through an NG tube.
3. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?
- A. Encourage a high-protein diet
- B. Apply a moisture-retentive dressing
- C. Provide daily wound irrigation
- D. Apply an ice pack to the wound
Correct answer: B
Rationale: The correct answer is to apply a moisture-retentive dressing. This promotes a moist wound environment, which is crucial for wound healing in clients with diabetes. Encouraging a high-protein diet may support overall health but is not directly related to wound healing. Daily wound irrigation can disrupt the wound healing process by removing necessary growth factors and cells. Applying an ice pack to the wound is contraindicated as it can impair circulation and delay wound healing.
4. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?
- A. Apply a heating pad to the wound
- B. Apply a moisture-retentive dressing
- C. Provide daily wound irrigation
- D. Apply an ice pack to the wound
Correct answer: B
Rationale: The correct answer is to apply a moisture-retentive dressing. This type of dressing promotes a moist wound environment, which is crucial for wound healing. Applying a heating pad can lead to tissue damage, while daily wound irrigation can disrupt the wound healing process. Applying an ice pack is not recommended for promoting wound healing in this scenario.
5. A nurse is assessing a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Nausea
- B. Decreased heart rate
- C. Weight gain
- D. Fever
Correct answer: A
Rationale: Nausea is a common symptom of intolerance to enteral feedings. When a client experiences nausea during enteral feeding, it can indicate issues such as feeding tube placement problems, formula intolerance, or gastroparesis. Nausea can lead to vomiting and further complications if not addressed promptly. Decreased heart rate, weight gain, and fever are not typically associated with intolerance to enteral feedings and would not be the primary indicators for this situation.
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