ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is caring for a client who reports a decrease in the effectiveness of their arthritis medication. What factor should the nurse identify as contributing to this decrease?
- A. Improved mobility
- B. Bowel inflammation
- C. Long-term use of the medication
- D. Frequent dehydration
Correct answer: B
Rationale: The correct answer is B: Bowel inflammation. Bowel inflammation can decrease the absorption of medications, reducing their effectiveness. Improved mobility (choice A) would generally not contribute to a decrease in medication effectiveness. Long-term use of the medication (choice C) may lead to tolerance but would not directly cause a decrease in effectiveness. Frequent dehydration (choice D) can affect overall health but is not a direct factor in the medication's effectiveness for arthritis.
2. 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.
3. A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?
- A. Reposition the client every 4 hours
- B. Use a special mattress for the client
- C. Keep the client on bedrest
- D. Encourage the client to remain in one position
Correct answer: B
Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.
4. A nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter. What is the nurse's first action?
- A. Irrigate the catheter with normal saline
- B. Notify the provider
- C. Assess for signs of infection
- D. Administer prescribed antibiotics
Correct answer: B
Rationale: The correct first action for the nurse to take when a client reports pain and tenderness at the site of an indwelling urinary catheter is to notify the provider. Pain and tenderness at the catheter site may indicate infection, and the healthcare provider needs to be informed for further assessment and appropriate interventions. Irrigating the catheter with normal saline (Choice A) should not be the initial action without consulting the provider first. While assessing for signs of infection (Choice C) is important, notifying the provider takes precedence. Administering prescribed antibiotics (Choice D) should only be done based on the provider's orders after assessment and confirmation of infection.
5. A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased physical activity
- B. Frequent urge suppression
- C. Increased fiber intake
- D. Decreased fluid intake
Correct answer: B
Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt normal bowel movements and result in constipation. Increased physical activity, increased fiber intake, and adequate fluid intake are measures that typically help prevent constipation by promoting bowel regularity and preventing stool hardening. Therefore, choices A, C, and D are not behaviors that increase the client's risk for constipation.
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