a nurse is teaching a client with a new prescription for a cane what instruction should the nurse include
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A client has a new prescription for a cane. What instruction should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Ensure the cane has a rubber tip.' This instruction is essential for safety as the rubber tip prevents slipping, providing stability. Choice A is incorrect because the cane should be held on the stronger side to provide better support and balance. Choice C is incorrect as the cane should be used on the stronger, more dominant side. Choice D is also incorrect as a cane is not only used on stairs but also for general support and mobility.

2. A nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter. What is the nurse's first action?

Correct answer: B

Rationale: The correct first action for the nurse to take when a client reports pain and tenderness at the site of an indwelling urinary catheter is to notify the provider. Pain and tenderness at the catheter site may indicate infection, and the healthcare provider needs to be informed for further assessment and appropriate interventions. Irrigating the catheter with normal saline (Choice A) should not be the initial action without consulting the provider first. While assessing for signs of infection (Choice C) is important, notifying the provider takes precedence. Administering prescribed antibiotics (Choice D) should only be done based on the provider's orders after assessment and confirmation of infection.

3. A nurse is planning a community education program about colorectal cancer. What risk factors should the nurse identify as modifiable?

Correct answer: B

Rationale: The correct answer is B: High-fat diet, smoking, alcohol consumption. These are modifiable risk factors for colorectal cancer as individuals can make lifestyle changes to reduce their risk. Age and gender (choice A) are non-modifiable risk factors. Ethnicity and race (choice C) can influence the risk of colorectal cancer but are not modifiable factors. Exposure to radiation (choice D) is not a common modifiable risk factor for colorectal cancer.

4. A nurse is caring for a client who reports pain at the site of an indwelling urinary catheter. What is the nurse's first action?

Correct answer: B

Rationale: The correct first action for the nurse to take when a client reports pain at the site of an indwelling urinary catheter is to notify the provider. Pain at the catheter site may indicate complications such as infection or blockage, which require further assessment and intervention by the healthcare provider. Irrigating the catheter, applying a warm compress, or administering pain medication should not be done without provider evaluation as they do not address the underlying cause of the pain and may potentially worsen the situation.

5. A nurse is completing an admission assessment for a client who has hearing loss. What action should the nurse take?

Correct answer: A

Rationale: Using written communication is the most effective action for a nurse when assessing a client with hearing loss. This method helps overcome communication barriers by providing information visually, ensuring the client understands the assessment questions and instructions. Speaking louder (choice B) may distort the sound and not necessarily improve understanding. Facing the client (choice C) is important for lip reading but may not be sufficient for effective communication. Providing care in a quiet environment (choice D) is beneficial but might not fully address the need for clear communication in the assessment process for a client with hearing loss.

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