ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is preparing to administer enteral feedings to a client with an NG tube. Which action should the nurse take first?
- A. Flush the tube with 100 mL of water
- B. Verify tube placement
- C. Elevate the head of the bed
- D. Measure the residual gastric volume
Correct answer: B
Rationale: Verifying tube placement is the priority action the nurse should take before administering enteral feedings. This step ensures that the NG tube is correctly positioned, reducing the risk of complications such as aspiration pneumonia. Flushing the tube with water, elevating the head of the bed, and measuring residual gastric volume are important steps in enteral feeding administration but come after verifying tube placement. Flushing the tube with water helps clear the tubing, elevating the head of the bed reduces the risk of aspiration, and measuring residual gastric volume helps assess the client's tolerance to feedings.
2. A nurse is caring for a client who is postoperative following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased physical activity
- B. Frequent urge suppression
- C. Adequate sleep
- D. Increased fluid intake
Correct answer: B
Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt the normal bowel movement pattern and lead to constipation. Choices A, C, and D are behaviors that generally help prevent constipation rather than increase the risk. Increased physical activity, adequate sleep, and increased fluid intake promote bowel regularity and reduce the risk of constipation.
3. A charge nurse is making assignments for the upcoming shift. Which client should the charge nurse assign to a licensed practical nurse (LPN)?
- A. A client requiring IV antibiotics for pneumonia
- B. A client requiring monitoring for dehydration
- C. A client with dehydration and inflammatory bowel disease
- D. A client admitted for surgical wound care
Correct answer: C
Rationale: The correct answer is C because a client with dehydration and inflammatory bowel disease is stable enough for care by an LPN. This condition does not require complex interventions that would necessitate a higher level of nursing care. Choice A is incorrect as administering IV antibiotics for pneumonia requires a higher level of nursing expertise. Choice B is incorrect because monitoring for dehydration may involve assessing vital signs and making critical decisions. Choice D is incorrect as providing care for surgical wound care involves wound assessment, dressing changes, and monitoring for signs of infection, which typically require a registered nurse.
4. A nurse is assessing a client who reports pain and redness at the site of a peripheral IV. What should the nurse do first?
- A. Apply a cold compress to the site
- B. Discontinue the IV line
- C. Notify the provider
- D. Increase the IV flow rate
Correct answer: B
Rationale: When a client reports pain and redness at the site of a peripheral IV, indicating signs of phlebitis, the nurse's initial action should be to discontinue the IV line. This helps prevent further complications and ensures patient safety. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider (Choice C) is important but not the initial step. Increasing the IV flow rate (Choice D) can exacerbate the inflammation and should be avoided.
5. When teaching about safety risks for adolescents, what should the nurse emphasize?
- A. Adolescents have a decreased risk of injury
- B. Peer pressure can lead to risky behaviors
- C. Increased responsibility reduces risks
- D. Adolescents are less likely to engage in substance abuse
Correct answer: B
Rationale: The correct answer is B: 'Peer pressure can lead to risky behaviors.' Adolescents are at an increased risk for injury due to peer pressure and the tendency to engage in high-risk behaviors. Emphasizing the impact of peer pressure on decision-making can help adolescents make safer choices. Choices A, C, and D are incorrect because adolescents actually have an increased risk of injury, increased responsibility does not always reduce risks, and many adolescents are at risk of engaging in substance abuse.
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