ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is caring for a client who has a prescription for a narcotic medication. What should the nurse do with the unused portion after administration?
- A. Store it in the medication cart for later use
- B. Discard it with a witness present
- C. Return it to the pharmacy
- D. Report it to the provider
Correct answer: B
Rationale: The correct action for the nurse to take with the unused portion of a narcotic medication after administration is to discard it with a witness present. This procedure is necessary to comply with controlled substance regulations and prevent diversion or misuse of the medication. Storing it in the medication cart for later use is inappropriate as it can lead to unauthorized access. Returning it to the pharmacy is not recommended as the medication has already been dispensed. Reporting it to the provider is not the standard procedure for disposing of controlled substances.
2. A nurse is assessing a client who reports a burning sensation at the site of a peripheral IV. The site is red and warm. What should the nurse do?
- A. Increase the IV flow rate
- B. Discontinue the IV line
- C. Apply a cold compress
- D. Elevate the limb
Correct answer: B
Rationale: When a client presents with symptoms of phlebitis at the IV site, such as redness, warmth, and pain, it is essential to discontinue the IV line. Increasing the IV flow rate could exacerbate the condition by further irritating the vein. Applying a cold compress may provide temporary relief but does not address the underlying issue of phlebitis. Elevating the limb is not the primary intervention for phlebitis and discontinuing the IV line takes precedence to prevent complications.
3. A nurse is caring for a client who is postoperative following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased physical activity
- B. Frequent urge suppression
- C. Adequate sleep
- D. Increased fluid intake
Correct answer: B
Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt the normal bowel movement pattern and lead to constipation. Choices A, C, and D are behaviors that generally help prevent constipation rather than increase the risk. Increased physical activity, adequate sleep, and increased fluid intake promote bowel regularity and reduce the risk of constipation.
4. A nurse is caring for a client who reports pain and burning around the peripheral IV site. What is the nurse's priority action?
- A. Apply a warm compress
- B. Discontinue the IV line
- C. Increase the IV flow rate
- D. Elevate the limb
Correct answer: B
Rationale: The correct answer is B: Discontinue the IV line. When a client reports pain and burning around the peripheral IV site, it indicates possible phlebitis, which is inflammation of the vein. The priority action is to discontinue the IV line to prevent further complications such as infection or thrombosis. Applying a warm compress (Choice A) may worsen the inflammation. Increasing the IV flow rate (Choice C) can exacerbate the symptoms and elevate the risk of complications. Elevating the limb (Choice D) may provide comfort, but it does not address the underlying issue of phlebitis. Therefore, the priority action is to discontinue the IV line.
5. 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.
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