ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is planning to administer several medications to a client through a nasogastric (NG) tube. What action should the nurse take?
- A. Dissolve crushed tablet medications in tap water
- B. Administer all medications together
- C. Flush the NG tube with 60 mL of water before each medication
- D. Dissolve medications separately and flush with sterile water
Correct answer: D
Rationale: The correct action for the nurse to take when administering medications through a nasogastric (NG) tube is to dissolve medications separately and flush the tube with sterile water. This is important to prevent interactions between medications and ensure accurate administration. Option A is incorrect because tap water may not be sterile and could lead to contamination. Option B is incorrect as it increases the risk of drug interactions and may affect the effectiveness of each medication. Option C is incorrect as 60 mL of water before each medication may not be enough to ensure proper medication delivery and prevent interactions.
2. A nurse is assessing a client who reports pain at the site of a peripheral IV. The site is red and warm. What is the nurse's priority action?
- A. Flush the IV line with saline
- B. Discontinue the IV infusion
- C. Apply a cold compress
- D. Increase the IV flow rate
Correct answer: B
Rationale: The correct answer is to discontinue the IV infusion. The signs of redness and warmth at the IV site indicate phlebitis, an inflammation of the vein. Discontinuing the IV infusion is crucial to prevent further complications such as infection or thrombosis. Flushing the IV line with saline would not address the underlying issue of phlebitis. Applying a cold compress may provide temporary relief but does not address the cause. Increasing the IV flow rate can exacerbate the inflammation and should be avoided.
3. A nurse is providing discharge teaching to a client who has a prescription for home oxygen therapy. What should the nurse teach?
- A. Remove the oxygen tubing during meals
- B. Wear synthetic fabrics while using oxygen
- C. Use cotton fabrics when oxygen is in use
- D. Increase oxygen flow during physical activity
Correct answer: C
Rationale: The correct answer is C: 'Use cotton fabrics when oxygen is in use.' When a client is on oxygen therapy, it is essential to use cotton fabrics to reduce the risk of static electricity, which can ignite in the presence of oxygen. Choices A, B, and D are incorrect. Removing the oxygen tubing during meals is not necessary as long as proper precautions are taken to avoid tripping hazards. Synthetic fabrics should be avoided while using oxygen therapy to prevent static electricity buildup. Increasing oxygen flow during physical activity should be done according to the healthcare provider's instructions, not indiscriminately.
4. 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.
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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