ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which client statement indicates an understanding of the teaching?
- A. Apply pressure directly to the wound
- B. Remove the dressings to assess the wound
- C. Use a clean dressing over the saturated one
- D. Apply alcohol to the wound
Correct answer: C
Rationale: The correct answer is C because placing a clean dressing over the saturated one helps maintain wound integrity and prevents further tissue damage. Choice A is incorrect as applying direct pressure to the wound is correct for controlling bleeding but not for dressing changes. Choice B is incorrect because removing dressings may disrupt wound healing and increase the risk of infection. Choice D is incorrect since applying alcohol to the wound can cause further irritation and damage to the tissues.
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 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.
4. A nurse is assessing a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Nausea
- B. Decreased heart rate
- C. Weight gain
- D. Fever
Correct answer: A
Rationale: Nausea is a common symptom of intolerance to enteral feedings. When a client experiences nausea during enteral feeding, it can indicate issues such as feeding tube placement problems, formula intolerance, or gastroparesis. Nausea can lead to vomiting and further complications if not addressed promptly. Decreased heart rate, weight gain, and fever are not typically associated with intolerance to enteral feedings and would not be the primary indicators for this situation.
5. A healthcare professional 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 professional use?
- A. Gait belt
- B. Mechanical lift
- C. Stand-assist lift
- D. Slide board
Correct answer: C
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 lift provides support and assistance for clients to stand up and be safely transferred. A gait belt is used for providing support during walking or transferring short distances for clients who need minimal assistance with balance and strength. A mechanical lift is typically used for clients who are non-weight bearing or have limited weight-bearing capacity. A slide board is utilized for transferring clients who are unable to bear weight on their legs and need assistance in sliding from one surface to another.
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