ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A healthcare professional is planning to administer an intramuscular injection to a client. What muscle should the healthcare professional choose to avoid injury?
- A. Deltoid
- B. Ventrogluteal
- C. Rectus femoris
- D. Dorsogluteal
Correct answer: B
Rationale: The ventrogluteal muscle is the preferred site for intramuscular injections to avoid injury. Choosing the ventrogluteal site reduces the risk of injury to major nerves and blood vessels, unlike the deltoid, rectus femoris, or dorsogluteal sites. The deltoid muscle is commonly used for vaccines but has a higher risk of injury due to its proximity to the radial nerve. The rectus femoris muscle is not recommended for intramuscular injections due to its location and the risk of injury. The dorsogluteal site is also not recommended as it poses a risk of injury to the sciatic nerve and superior gluteal artery.
2. While documenting client care, which entry should the nurse identify as an example of implementing client care?
- A. Documenting the client's pain level
- B. Monitoring the client's urine output
- C. Assessing the client's range of motion
- D. Contacting the provider to report client findings
Correct answer: D
Rationale: The correct answer is D because contacting the provider to report client findings is an example of implementing care. Implementation involves putting the care plan into action based on assessment data. While options A, B, and C are important aspects of client care, they mainly focus on assessment rather than the actual implementation of care.
3. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?
- A. Palpate the abdomen before auscultation
- B. Inspect the abdomen after palpation
- C. Auscultate before palpation
- D. Start by percussing the abdomen
Correct answer: C
Rationale: The correct answer is to auscultate before palpation when performing an abdominal assessment. This sequence is crucial to prevent altering bowel sounds. Starting with palpation (Choice A) can lead to false interpretations of bowel sounds due to stimulation of the intestines. Inspecting the abdomen after palpation (Choice B) can also potentially alter the assessment findings. Starting with percussion (Choice D) is not recommended as it should come after auscultation to further assess underlying structures.
4. A healthcare professional is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. What finding should the healthcare professional expect?
- A. Decreased respiratory rate
- B. Flushing of the skin
- C. Flaring of the nostrils
- D. Productive cough
Correct answer: C
Rationale: Flaring of the nostrils is a sign of increased respiratory effort, which is common in clients with COPD experiencing dyspnea. Choices A, B, and D are incorrect. A decreased respiratory rate is not expected in a client with COPD experiencing dyspnea, as they often have an increased respiratory rate. Flushing of the skin is not a typical finding associated with COPD or dyspnea. While a productive cough can be seen in COPD, it is not specifically related to the increased respiratory effort seen with dyspnea.
5. A client has a new prescription for a cane. What instruction should the nurse include?
- A. Hold the cane on the weaker side
- B. Ensure the cane has a rubber tip
- C. Keep the cane on the dominant side
- D. Use the cane only on stairs
Correct answer: B
Rationale: The correct instruction the nurse should include is to ensure the cane has a rubber tip. This is important as it prevents slipping and ensures safety while walking. Choice A is incorrect because the cane should be held on the stronger side to provide better support. Choice C is incorrect as the cane should be used on the stronger, not the dominant, side for stability. Choice D is incorrect because a cane can be used for support in various situations, not just on stairs.
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