ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A client with diabetes mellitus has a foot ulcer. What is an appropriate intervention to promote wound healing?
- A. Apply a heating pad to the wound
- B. Apply a moisture-retentive dressing
- C. Provide daily wound irrigation
- D. Apply an ice pack to the wound
Correct answer: B
Rationale: The correct answer is to apply a moisture-retentive dressing. This type of dressing promotes a moist wound environment, which is crucial for wound healing. Applying a heating pad can lead to tissue damage, while daily wound irrigation can disrupt the wound healing process. Applying an ice pack is not recommended for promoting wound healing in this scenario.
2. A nurse is caring for a client who reports a decrease in the effectiveness of their pain medication. What factor should the nurse identify as contributing to this decrease?
- A. History of frequent alcohol use
- B. Decreased physical activity
- C. Bowel inflammation
- D. History of opioid use
Correct answer: C
Rationale: The correct answer is C: Bowel inflammation. Bowel inflammation can interfere with the absorption of medications, including pain medication, leading to decreased effectiveness. Choices A, B, and D are incorrect because although they can impact pain management in various ways, they are not directly related to the decreased effectiveness of pain medication due to absorption issues.
3. A client expresses anxiety about an upcoming surgery. What should the nurse do?
- A. Administer a sedative
- B. Ask the client to describe their feelings
- C. Call the surgeon to address the anxiety
- D. Provide information on post-op care
Correct answer: B
Rationale: When a client expresses anxiety, it is essential for the nurse to encourage the client to verbalize their feelings. This helps the client express concerns, fears, and uncertainties, enabling the nurse to provide appropriate emotional support. Administering a sedative (Choice A) should not be the initial response as it does not address the underlying emotional needs of the client. Calling the surgeon to address anxiety (Choice C) may not be within the nurse's scope of practice and may not directly address the client's emotional needs. Providing information on post-op care (Choice D) is important but not the priority when the client is experiencing anxiety preoperatively.
4. A nurse is caring for a client who reports pain 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. Apply a warm compress to the site
- D. Administer pain medication
Correct answer: B
Rationale: The correct first action for the nurse to take when a client reports pain at the site of an indwelling urinary catheter is to notify the provider. Pain at the catheter site may indicate complications such as infection or blockage, which require further assessment and intervention by the healthcare provider. Irrigating the catheter, applying a warm compress, or administering pain medication should not be done without provider evaluation as they do not address the underlying cause of the pain and may potentially worsen the situation.
5. A client who is at risk for developing a deep vein thrombosis (DVT) after surgery. What intervention should the nurse implement to reduce this risk?
- A. Avoid ambulation to prevent injury
- B. Use compression stockings
- C. Use a heating pad for comfort
- D. Elevate the client's legs on a pillow
Correct answer: B
Rationale: The correct intervention to reduce the risk of deep vein thrombosis (DVT) after surgery is to use compression stockings. Compression stockings help prevent DVT by promoting venous return, which reduces the likelihood of blood pooling in the legs and forming clots. Choices A, C, and D are incorrect because avoiding ambulation can actually increase the risk of DVT, using a heating pad does not directly address DVT prevention, and elevating the client's legs on a pillow alone may not provide sufficient compression to prevent DVT.
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