ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is caring for a client who has an indwelling urinary catheter. What finding indicates a catheter occlusion?
- A. Bladder distention
- B. Bladder spasms
- C. Hematuria
- D. Increased urine output
Correct answer: A
Rationale: Bladder distention is the correct finding that indicates a catheter occlusion. When the catheter is occluded, urine cannot drain properly, leading to the build-up of urine in the bladder, causing distention. Bladder spasms (Choice B) are not typically associated with catheter occlusion but may indicate irritation or infection. Hematuria (Choice C) refers to blood in the urine and is not specific to catheter occlusion. Increased urine output (Choice D) is not indicative of catheter occlusion but may suggest other conditions like diabetes insipidus.
2. A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?
- A. Negligence
- B. Assault
- C. Battery
- D. Defamation
Correct answer: A
Rationale: The correct answer is A: Negligence. Negligence in nursing occurs when a healthcare provider fails to take appropriate action that a reasonably prudent provider would take in a similar situation, such as not notifying the provider of changes in a client's condition. In this scenario, the nurse's failure to inform the provider of the client's changed condition constitutes negligence. Choices B, C, and D are incorrect. Assault involves the intentional threat of bodily harm to another person, battery is the intentional harmful or offensive touching of another person without their consent, and defamation is the act of making false statements about someone to a third party that harms that person's reputation.
3. A client with diabetes mellitus is being taught about foot care. What statement by the client indicates an understanding of the teaching?
- A. I will soak my feet in warm water every day
- B. I will wear slippers at all times when out of bed
- C. I will apply lotion between my toes after washing my feet
- D. I will cut my toenails straight across
Correct answer: B
Rationale: The correct answer is B. Wearing slippers or shoes at all times when out of bed is crucial for clients with diabetes mellitus to protect their feet from injury. Option A is incorrect as soaking feet in warm water can lead to dry skin, making it more susceptible to injuries. Option C is incorrect as applying lotion between the toes can create a moist environment, increasing the risk of fungal infections. Option D is incorrect as cutting toenails straight across is a good practice but is not directly related to preventing foot injuries in clients with diabetes.
4. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?
- A. Steamed carrots
- B. Mashed potatoes
- C. Orange slices
- D. Soft-cooked eggs
Correct answer: C
Rationale: The correct answer is C: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices have membranes that can be challenging to consume for individuals with swallowing difficulties. Steamed carrots (Choice A) and mashed potatoes (Choice B) are typically suitable for a mechanical soft diet as they can be easily mashed or cut into smaller pieces. Soft-cooked eggs (Choice D) are also appropriate for this diet as they are soft and easy to chew.
5. A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. What action should the nurse take?
- A. Dissolve crushed tablet medications in tap water
- B. Administer all medications together
- C. Flush the NG tube with 60 mL of water before each medication
- D. Dissolve medications separately and flush with sterile water
Correct answer: D
Rationale: The correct action for the nurse to take when administering medications through a nasogastric (NG) tube is to dissolve medications separately and flush the tube with sterile water. This is important to prevent interactions between medications and ensure accurate administration. Option A is incorrect because tap water may not be sterile and could lead to contamination. Option B is incorrect as it increases the risk of drug interactions and may affect the effectiveness of each medication. Option C is incorrect as 60 mL of water before each medication may not be enough to ensure proper medication delivery and prevent interactions.
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