ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is teaching a client with diabetes mellitus about foot care. What is the most important instruction the nurse should include?
- A. Apply lotion between the toes after bathing
- B. Inspect feet daily for injuries
- C. Wear shoes only indoors
- D. Cut toenails in a rounded shape
Correct answer: B
Rationale: Inspecting feet daily for injuries is crucial for clients with diabetes to prevent unnoticed wounds from becoming infected. This instruction is the most important as it helps in early detection and management of foot problems. Choice A is incorrect because applying lotion between the toes can lead to excessive moisture, increasing the risk of fungal infections. Choice C is wrong as wearing shoes indoors can also lead to foot issues. Choice D is incorrect because cutting toenails in a rounded shape can result in ingrown toenails, posing a risk for infection.
2. A nurse is caring for a client who reports burning around the peripheral IV site. What finding should the nurse identify as a manifestation of infiltration?
- A. Bruising at the IV site
- B. Edema at the IV site
- C. Warmth along the IV site
- D. Pallor at the IV site
Correct answer: B
Rationale: Edema at the IV site is a common sign of infiltration, where fluid leaks into the surrounding tissue. Bruising at the IV site (Choice A) is more indicative of hematoma formation, warmth along the IV site (Choice C) may suggest infection, and pallor at the IV site (Choice D) is not a typical sign of infiltration.
3. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. Which food should the nurse instruct the client to avoid?
- A. Steamed carrots
- B. Orange slices
- C. Mashed potatoes
- D. Baked chicken
Correct answer: B
Rationale: Correct! Orange slices should be avoided by clients on a mechanical soft diet as they can be difficult to chew and swallow. Steamed carrots, mashed potatoes, and baked chicken are suitable choices for a mechanical soft diet, as they are softer in texture and easier to consume without posing a risk of choking or swallowing difficulties.
4. A nurse is caring for a client who has a prescription for a narcotic medication. What should the nurse do with the unused portion after administration?
- A. Store it in the medication cart for later use
- B. Discard it with a witness present
- C. Return it to the pharmacy
- D. Report it to the provider
Correct answer: B
Rationale: The correct action for the nurse to take with the unused portion of a narcotic medication after administration is to discard it with a witness present. This procedure is necessary to comply with controlled substance regulations and prevent diversion or misuse of the medication. Storing it in the medication cart for later use is inappropriate as it can lead to unauthorized access. Returning it to the pharmacy is not recommended as the medication has already been dispensed. Reporting it to the provider is not the standard procedure for disposing of controlled substances.
5. A client with a new diagnosis of diabetes mellitus needs instruction on foot care. What advice should the nurse provide?
- A. Soak feet in warm water daily
- B. Wear shoes at all times
- C. Cut toenails in a rounded shape
- D. Inspect the feet weekly
Correct answer: B
Rationale: The correct answer is B: 'Wear shoes at all times.' This instruction is crucial for clients with diabetes as it helps protect the feet from potential injuries. Choice A of soaking feet in warm water daily can lead to skin issues and should be avoided. Cutting toenails in a rounded shape, as mentioned in choice C, can increase the risk of ingrown toenails. While inspecting the feet weekly, as in choice D, is important, wearing shoes at all times is a more preventative measure to avoid foot injuries in diabetic clients.
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