ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A client is being taught about measures to promote sleep for insomnia. Which client statement indicates understanding?
- A. I will take naps during the day to help me sleep at night
- B. I should drink caffeine to help me stay awake during the day
- C. I should reduce my fluid intake 2 hours before bedtime
- D. I should exercise right before bed to tire myself out
Correct answer: C
Rationale: The correct answer is C. By reducing fluid intake 2 hours before bedtime, the client can prevent nighttime awakenings to urinate, which promotes better sleep. Napping during the day (choice A) may interfere with nighttime sleep. Drinking caffeine (choice B) can disrupt sleep patterns. Exercising right before bed (choice D) can actually stimulate the body and make it harder to fall asleep.
2. A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased physical activity
- B. Frequent urge suppression
- C. Increased fiber intake
- D. Decreased fluid intake
Correct answer: B
Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt normal bowel movements and result in constipation. Increased physical activity, increased fiber intake, and adequate fluid intake are measures that typically help prevent constipation by promoting bowel regularity and preventing stool hardening. Therefore, choices A, C, and D are not behaviors that increase the client's risk for constipation.
3. 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.
4. When teaching a client about the correct use of a cane, what should the nurse include?
- A. Hold the cane on the weaker side
- B. Ensure the cane has a rubber tip
- C. Keep the cane on the dominant side
- D. Use the cane only on stairs
Correct answer: B
Rationale: The correct answer is B. When instructing a client on the use of a cane, it is essential to ensure that the cane has a rubber tip. This rubber tip helps prevent slipping, providing additional stability and safety. Option A, holding the cane on the weaker side, is incorrect as the cane should be held on the stronger side to provide better balance and support. Option C, keeping the cane on the dominant side, is also incorrect because the cane should be held on the stronger side. Option D, using the cane only on stairs, is not comprehensive as the cane can be used for support and balance while walking on level ground as well.
5. A nurse is teaching a client about ways to reduce the risk of deep vein thrombosis (DVT) after surgery. What should the nurse include in the teaching?
- A. Rest in bed for long periods
- B. Use sequential compression devices
- C. Avoid leg exercises
- D. Keep legs crossed
Correct answer: B
Rationale: The correct answer is to 'Use sequential compression devices.' Sequential compression devices help prevent DVT by promoting venous return, reducing stasis in the veins, and preventing blood clot formation. Resting in bed for long periods (Choice A) can actually increase the risk of DVT due to decreased mobility. Avoiding leg exercises (Choice C) is also not recommended as mobilization and exercises can help prevent blood clots. Keeping legs crossed (Choice D) can impede blood flow and is not advisable in reducing the risk of DVT.
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