ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is teaching a group of assistive personnel about expected integumentary changes in older adults. What change should the nurse include?
- A. Increase in oil production
- B. Decrease in elasticity
- C. Increase in pigmentation
- D. Decrease in moisture levels
Correct answer: B
Rationale: The correct answer is B: Decrease in elasticity. As individuals age, their skin tends to lose elasticity, becoming less flexible. This results in wrinkles and sagging skin. Option A, increase in oil production, is not typically an expected integumentary change in older adults. Option C, increase in pigmentation, may occur due to sun exposure or age spots but is not a universal change. Option D, decrease in moisture levels, is not a primary integumentary change associated with aging.
2. A client is being taught by a nurse about the correct use of a metered-dose inhaler (MDI). What instruction should the nurse include?
- A. Inhale for 1 second
- B. Hold the inhaler 1-2 inches from the mouth
- C. Exhale immediately after inhaling
- D. Hold the inhaler directly at the lips
Correct answer: B
Rationale: The correct instruction the nurse should include when teaching a client about using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance ensures proper delivery of the medication into the airways. Choices A, C, and D are incorrect because inhaling for a specific duration, exhaling immediately after inhaling, or holding the inhaler directly at the lips are not recommended practices for the correct use of an MDI.
3. A nurse is reviewing a client's health history and identifies chronic constipation as a potential complication of immobility. What intervention should the nurse include in the plan of care?
- A. Increase fiber intake
- B. Encourage the client to walk daily
- C. Use a stool softener as needed
- D. Use a laxative daily
Correct answer: A
Rationale: Increasing fiber intake is the appropriate intervention to include in the plan of care for a client with chronic constipation due to immobility. Fiber helps add bulk to the stool, making it easier to pass, thereby preventing constipation. Encouraging the client to walk daily (choice B) is also beneficial as it promotes mobility and can help alleviate constipation associated with immobility. Using a stool softener as needed (choice C) and using a laxative daily (choice D) are not the first-line interventions for managing constipation related to immobility. Stool softeners and laxatives should be used judiciously and under healthcare provider guidance.
4. A healthcare professional is preparing to administer an intramuscular injection to a client. What is the appropriate site for the injection to avoid injury?
- A. Deltoid
- B. Ventrogluteal
- C. Rectus femoris
- D. Dorsogluteal
Correct answer: B
Rationale: The ventrogluteal site is the preferred site for intramuscular injections to avoid injury to nerves or blood vessels. The deltoid site is commonly used for vaccines but has a higher risk of hitting the radial nerve. The rectus femoris site is not typically recommended for intramuscular injections. The dorsogluteal site is contraindicated due to the proximity to the sciatic nerve and major blood vessels.
5. A nurse is preparing to administer enteral feedings to a client with an NG tube. Which action should the nurse take first?
- A. Flush the tube with 100 mL of water
- B. Verify tube placement
- C. Elevate the head of the bed
- D. Measure the residual gastric volume
Correct answer: B
Rationale: Verifying tube placement is the priority action the nurse should take before administering enteral feedings. This step ensures that the NG tube is correctly positioned, reducing the risk of complications such as aspiration pneumonia. Flushing the tube with water, elevating the head of the bed, and measuring residual gastric volume are important steps in enteral feeding administration but come after verifying tube placement. Flushing the tube with water helps clear the tubing, elevating the head of the bed reduces the risk of aspiration, and measuring residual gastric volume helps assess the client's tolerance to feedings.
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