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PN ATI Capstone Fundamentals Quiz
1. A nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?
- A. Heart rate 120/min
- B. Urine output 30 mL/hour
- C. Blood pressure 110/70 mmHg
- D. Skin turgor is normal
Correct answer: A
Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement. Elevated heart rate is a sensitive indicator of dehydration as the body attempts to maintain cardiac output. Urine output of 30 mL/hour is within the normal range (30 mL/hour is the minimum acceptable urine output for an adult). Blood pressure of 110/70 mmHg is within the normal range. Normal skin turgor is a positive sign indicating adequate hydration.
2. A nurse is admitting a client who has meningococcal meningitis. What should the nurse do first?
- A. Initiate droplet precautions
- B. Start intravenous antibiotics
- C. Perform a complete assessment
- D. Notify the healthcare provider
Correct answer: A
Rationale: The first priority when admitting a client with meningococcal meningitis is to initiate droplet precautions. This is essential to prevent the transmission of the infection to others, as meningococcal meningitis is highly contagious through respiratory droplets. Starting intravenous antibiotics or performing a complete assessment can follow, but the immediate concern is to implement infection control measures. Notifying the healthcare provider should also be done but is not the first action to take in this situation.
3. A healthcare provider is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the healthcare provider use?
- A. A wheelchair
- B. A stand-assist lift
- C. A transfer belt
- D. A slide board
Correct answer: B
Rationale: A stand-assist lift is the most suitable device for transferring a client who can bear partial weight and has upper body strength. This device provides support and assistance for the client to stand up and transfer safely. Choice A, a wheelchair, is not designed for this purpose and is used for mobility. Choice C, a transfer belt, is helpful for providing stability during transfers but may not be sufficient for a client with partial weight-bearing. Choice D, a slide board, is more suitable for transferring clients who are unable to bear weight and need assistance for lateral transfers.
4. A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which of the following behaviors should the nurse identify as increasing the client's risk for constipation?
- A. Regular fluid intake
- B. Urge suppression
- C. Increased physical activity
- D. Adequate dietary fiber
Correct answer: B
Rationale: Urge suppression can lead to constipation by delaying bowel movements and causing fecal impaction, especially in postoperative patients. Regular fluid intake (choice A) is important to prevent constipation by maintaining hydration and aiding in bowel movements. Increased physical activity (choice C) helps stimulate bowel function and prevent constipation. Adequate dietary fiber (choice D) is essential for promoting healthy bowel movements and preventing constipation. However, urge suppression (choice B) is the behavior that directly contributes to constipation in this scenario.
5. A healthcare provider is reviewing the health history of an older adult who has a hip fracture. The healthcare provider should identify what as a risk factor for developing pressure injuries?
- A. Advanced age
- B. Urinary incontinence
- C. Regular skin assessments
- D. Adequate hydration
Correct answer: B
Rationale: Urinary incontinence is a significant risk factor for skin breakdown and pressure injuries. It can lead to prolonged skin exposure to moisture and irritants, increasing the susceptibility to pressure injuries. Advanced age (Choice A) is a risk factor due to changes in skin integrity and decreased tissue viability, but it is not as direct a risk factor as urinary incontinence. Regular skin assessments (Choice C) are important for early detection and prevention but are not a risk factor themselves. Adequate hydration (Choice D) is essential for overall skin health but is not a direct risk factor for pressure injuries.
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