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. When providing discharge teaching to a client prescribed home oxygen therapy, what information should the nurse include?
- A. Increase the oxygen flow rate during activity
- B. Avoid smoking and open flames near oxygen
- C. Store the oxygen tank in a warm, dry place
- D. Turn off the oxygen when not in use
Correct answer: B
Rationale: The correct answer is B: 'Avoid smoking and open flames near oxygen.' This information is crucial to prevent fire hazards when using home oxygen therapy. Smoking and open flames near oxygen can lead to serious accidents. Choice A is incorrect because increasing the oxygen flow rate during activity without healthcare provider guidance can be dangerous. Choice C is incorrect as oxygen tanks should be stored in a well-ventilated area, not necessarily warm and dry. Choice D is incorrect as oxygen should not be turned off and on by the client, as it can affect the therapy's effectiveness and cause safety issues.
3. A nurse is preparing to perform a sterile dressing change for a client who has a surgical wound. What should the nurse do to prevent contamination?
- A. Wear non-sterile gloves
- B. Apply sterile gloves over non-sterile gloves
- C. Change gloves if the sterile solution splashes onto the sterile field
- D. Cover the sterile field with a sterile drape
Correct answer: C
Rationale: The correct answer is C. If sterile solution splashes onto the sterile field, it is considered contaminated. Changing gloves in this situation ensures that the sterility of the dressing change is maintained. Choice A is incorrect as non-sterile gloves would introduce contaminants. Choice B is incorrect as layering gloves can increase the risk of contamination. Choice D is incorrect as covering the sterile field with a sterile drape is not the appropriate action to take in response to contamination.
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 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.
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