ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A client with diabetes mellitus is being taught about foot care by a nurse. What statement indicates understanding?
- A. I will soak my feet in hot water every day
- B. I will wear cotton socks at all times
- C. I will cut my toenails in a rounded shape
- D. I will apply lotion between my toes after bathing
Correct answer: B
Rationale: The correct answer is B. Wearing cotton socks is essential for clients with diabetes as it helps protect the feet and reduces the risk of skin breakdown. Choice A is incorrect because soaking feet in hot water can lead to burns or skin damage. Choice C is incorrect as clients with diabetes should cut their toenails straight across to prevent ingrown toenails. Choice D is incorrect as applying lotion between the toes can create a moist environment that may increase the risk of fungal infections.
2. In the care plan of a male patient diagnosed with a dissociative disorder, the nursing diagnosis of ineffective coping is included. Which behavior demonstrated by the patient supports this nursing diagnosis?
- A. Has no memory of the physical abuse he endured.
- B. Using both alcohol and marijuana.
- C. Often reports being unaware of surroundings.
- D. Reports feelings of 'not really being here.'
Correct answer: B
Rationale: The correct answer is B because using substances like alcohol and marijuana can be a sign of ineffective coping mechanisms in patients with dissociative disorders. Substance abuse is often used as a maladaptive way to cope with stress, trauma, or other underlying issues. Choices A, C, and D may be related to dissociative symptoms but do not directly reflect ineffective coping behaviors as substance abuse does.
3. A patient with schizophrenia is prescribed clozapine. Which potential side effect requires regular monitoring?
- A. Weight loss
- B. Hypertension
- C. Agranulocytosis
- D. Hyperthyroidism
Correct answer: C
Rationale: When a patient with schizophrenia is prescribed clozapine, regular monitoring for agranulocytosis is essential. Agranulocytosis is a severe reduction in white blood cells that can be life-threatening. Monitoring white blood cell counts is crucial to detect this side effect early and prevent serious complications. Weight loss (Choice A) is not a common side effect of clozapine. Hypertension (Choice B) and hyperthyroidism (Choice D) are also not typically associated with clozapine use, making them incorrect choices for regular monitoring.
4. A nurse is caring for a client following an esophagogastroduodenoscopy (EGD). Which of the following assessments is the nurse's priority?
- A. Level of consciousness
- B. Pain
- C. Nausea
- D. Gag reflex
Correct answer: D
Rationale: The correct answer is assessing the gag reflex. This is the priority assessment following an EGD procedure to prevent aspiration. Checking the gag reflex helps ensure the client's airway protection. Assessing the level of consciousness is important, but ensuring the client can protect their airway takes precedence. Pain and nausea assessments are also essential but are secondary to maintaining airway patency.
5. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?
- A. Instruct the client to observe strict bed rest
- B. Check for epidural catheter drainage
- C. Administer analgesia through the epidural catheter as prescribed
- D. Assess respiratory rate carefully
Correct answer: D
Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.
Similar Questions
Access More Features
ATI Basic
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI Basic
- 50,000 Questions with answers
- All ATI courses Coverage
- 90 days access @ $149.99