ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A charge nurse is making assignments for the upcoming shift. Which client should the charge nurse assign to a licensed practical nurse (LPN)?
- A. A client requiring IV antibiotics for pneumonia
- B. A client requiring monitoring for dehydration
- C. A client with dehydration and inflammatory bowel disease
- D. A client admitted for surgical wound care
Correct answer: C
Rationale: The correct answer is C because a client with dehydration and inflammatory bowel disease is stable enough for care by an LPN. This condition does not require complex interventions that would necessitate a higher level of nursing care. Choice A is incorrect as administering IV antibiotics for pneumonia requires a higher level of nursing expertise. Choice B is incorrect because monitoring for dehydration may involve assessing vital signs and making critical decisions. Choice D is incorrect as providing care for surgical wound care involves wound assessment, dressing changes, and monitoring for signs of infection, which typically require a registered nurse.
2. A nurse is assessing a client who has received intermittent enteral feedings. What finding indicates the client is tolerating the feeding?
- A. Nausea and vomiting
- B. Normal bowel sounds
- C. Weight gain
- D. Decreased abdominal distention
Correct answer: D
Rationale: The correct answer is D: Decreased abdominal distention. This finding indicates that the client is tolerating the feeding well without experiencing bloating or discomfort. Nausea and vomiting (choice A) are symptoms of intolerance to enteral feedings. Normal bowel sounds (choice B) are a good sign but do not directly indicate tolerance to the feeding. Weight gain (choice C) may occur due to factors other than enteral feedings.
3. A nurse is monitoring a client receiving intermittent enteral feedings. What should the nurse identify as a sign of intolerance to the feeding?
- A. Decreased heart rate
- B. Nausea
- C. Fever
- D. Weight gain
Correct answer: B
Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Nausea can indicate various issues such as feeding intolerance, formula composition problems, or underlying medical conditions. Decreased heart rate, fever, and weight gain are not typical signs of feeding intolerance. Decreased heart rate and fever may indicate other medical conditions, while weight gain is not an immediate sign of intolerance to enteral feedings.
4. When providing discharge teaching to a client prescribed home oxygen therapy, what information should the nurse include?
- A. Increase the oxygen flow rate during activity
- B. Avoid smoking and open flames near oxygen
- C. Store the oxygen tank in a warm, dry place
- D. Turn off the oxygen when not in use
Correct answer: B
Rationale: The correct answer is B: 'Avoid smoking and open flames near oxygen.' This information is crucial to prevent fire hazards when using home oxygen therapy. Smoking and open flames near oxygen can lead to serious accidents. Choice A is incorrect because increasing the oxygen flow rate during activity without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored in a well-ventilated area, not necessarily warm and dry. Choice D is incorrect as oxygen should not be turned off and on by the client, as it can affect the therapy's effectiveness and cause safety issues.
5. A client is being taught how to use a cane. Which instruction should the nurse include?
- A. Use the cane on the stronger side
- B. Use the cane on the weaker side
- C. Ensure the cane has a rubber tip
- D. Hold the cane 1-2 inches from the ground
Correct answer: A
Rationale: The correct answer is to use the cane on the stronger side. This instruction is important because it provides better support and balance. Placing the cane on the stronger side helps to shift weight off the weaker or injured side, reducing the risk of falls and promoting stability. Choices B, C, and D are incorrect. Using the cane on the weaker side would not provide optimal support. While ensuring the cane has a rubber tip and holding it 1-2 inches from the ground are important, they are not as crucial as using the cane on the stronger side for proper support and balance.
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