a nurse is caring for a client who has an indwelling urinary catheter what should the nurse identify as a sign of catheter occlusion
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Nursing Elites

ATI RN

ATI Capstone Fundamentals Assessment Proctored

1. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?

Correct answer: B

Rationale: The correct answer is B: Bladder distention. Bladder distention is a sign of catheter occlusion because it indicates a failure to drain urine properly. Bladder spasms (Choice A) are more commonly associated with bladder irritability rather than catheter occlusion. Frequent urination (Choice C) is unlikely in a client with an indwelling catheter as the urine should be draining continuously. Hematuria (Choice D) refers to blood in the urine and is not typically a direct sign of catheter occlusion.

2. A healthcare provider is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the provider identify as examples of cultural variables?

Correct answer: B

Rationale: The correct answer is B: Eye contact, personal space, and touch are cultural variables that can influence healthcare interactions. These factors vary across cultures and can impact how individuals perceive communication and interactions. Choices A, C, and D include elements that are not specifically cultural variables affecting communication and interactions in the same way as eye contact, personal space, and touch.

3. A healthcare provider is preparing to perform a routine abdominal assessment. What action should the healthcare provider take first?

Correct answer: A

Rationale: The correct first action in a routine abdominal assessment is to inspect the abdomen. This allows the healthcare provider to visually assess for any visible abnormalities such as scars, distention, or masses. Auscultating bowel sounds comes after inspection as the second step to assess bowel motility. Palpation and percussion follow in the sequence of a comprehensive abdominal assessment. Therefore, inspecting the abdomen is the priority to gather initial information before proceeding with further assessment techniques.

4. A nurse is providing discharge teaching for a client with a prescription for home oxygen therapy. Which instruction should the nurse include?

Correct answer: B

Rationale: The correct instruction for a client with home oxygen therapy is to keep oxygen tubing away from heat sources to prevent fires and other hazards. Option A is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Option C is incorrect as synthetic fabrics can generate static electricity, which is a fire hazard. Option D is incorrect as oxygen should be left on as prescribed unless advised otherwise.

5. A nurse in a provider's office is assessing the motor skill development of a 15-month-old toddler during a well-child visit. What gross motor skill should the nurse expect?

Correct answer: C

Rationale: At 15 months, a toddler should be able to walk without assistance. Walking without assistance is a major gross motor skill milestone at this age, indicating the child's physical development and coordination. Choices A, B, and D are developmentally inappropriate for a 15-month-old. Jumping with both feet, running with coordination, and kicking a ball forward typically develop later in a child's growth and are more advanced skills compared to walking independently.

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