ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. When teaching about safety risks for adolescents, what should the nurse emphasize?
- A. Adolescents have a decreased risk of injury
- B. Peer pressure can lead to risky behaviors
- C. Increased responsibility reduces risks
- D. Adolescents are less likely to engage in substance abuse
Correct answer: B
Rationale: The correct answer is B: 'Peer pressure can lead to risky behaviors.' Adolescents are at an increased risk for injury due to peer pressure and the tendency to engage in high-risk behaviors. Emphasizing the impact of peer pressure on decision-making can help adolescents make safer choices. Choices A, C, and D are incorrect because adolescents actually have an increased risk of injury, increased responsibility does not always reduce risks, and many adolescents are at risk of engaging in substance abuse.
2. A nurse is preparing to perform a focused respiratory assessment on a client with COPD. What is an expected finding?
- A. Normal respiratory rate
- B. Nasal flaring
- C. Decreased breath sounds
- D. Increased breath sounds
Correct answer: B
Rationale: Nasal flaring is an expected finding in clients with COPD who are experiencing respiratory distress. Nasal flaring is a sign of increased work of breathing and respiratory distress, commonly seen in clients with COPD exacerbation. Choices A, C, and D are incorrect. A normal respiratory rate would not be an expected finding in a client with COPD, as they often have an increased respiratory rate. Decreased breath sounds could indicate diminished airflow but are not typically a common finding in COPD. Increased breath sounds are not typical in COPD and could indicate other conditions like pneumonia.
3. A client who has recently developed fever, confusion, and a decreased level of consciousness is being admitted by a nurse. What should the nurse do first after obtaining the client's history and assessment?
- A. Administer prescribed antibiotics
- B. Initiate seizure precautions
- C. Identify the client's needs
- D. Place the client in isolation
Correct answer: C
Rationale: The correct answer is to identify the client's needs first. This allows the nurse to prioritize interventions based on the assessment findings. Administering prescribed antibiotics (choice A) should be based on a medical prescription and the identified infection. Initiating seizure precautions (choice B) is important but not the immediate priority in this case. Placing the client in isolation (choice D) is premature as the nurse needs to first assess and address the client's condition.
4. A nurse is updating the plan of care for a client with limited mobility. What intervention should the nurse include to prevent skin breakdown?
- A. Reposition the client every 4 hours
- B. Apply lotion to the skin every 2 hours
- C. Use a special mattress to reduce pressure on the skin
- D. Increase fluid intake to promote skin hydration
Correct answer: C
Rationale: The correct answer is C: 'Use a special mattress to reduce pressure on the skin.' This intervention is crucial in preventing skin breakdown in clients with limited mobility as it helps to reduce pressure on bony prominences. Repositioning every 4 hours (Choice A) is important but may not be sufficient to prevent skin breakdown entirely. Applying lotion every 2 hours (Choice B) may not address the root cause of skin breakdown related to pressure. Increasing fluid intake (Choice D) is beneficial for overall skin health but may not directly prevent skin breakdown caused by pressure points.
5. A nurse is preparing to perform a routine abdominal assessment. Which action should the nurse take first?
- A. Percuss the abdomen
- B. Auscultate bowel sounds
- C. Inspect the abdomen
- D. Palpate the abdomen
Correct answer: B
Rationale: The correct answer is to auscultate bowel sounds. Auscultation should be performed before palpation during an abdominal assessment to avoid altering bowel sounds. Inspecting the abdomen is important but should follow auscultation. Percussion and palpation should be done after auscultation and inspection to ensure an accurate assessment.
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