ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is preparing to administer medications to a client through a nasogastric (NG) tube. Which action should the nurse take?
- A. Crush all the medications and mix them together in water
- B. Flush the NG tube with 10 mL of air before each medication
- C. Dissolve each medication separately and flush with water between medications
- D. Administer all medications at the same time
Correct answer: C
Rationale: The correct action for the nurse to take when administering medications through an NG tube is to dissolve each medication separately and flush with water between medications. This practice helps prevent interactions between medications and ensures that each medication is delivered effectively. Option A is incorrect as mixing all medications together can lead to chemical interactions or alter the effectiveness of the medications. Option B is incorrect because flushing the NG tube with air is not recommended and may cause harm. Option D is incorrect as administering all medications at the same time does not allow for proper absorption and interaction control.
2. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?
- A. Avoid discussing the deceased
- B. Encourage the partner to ask for help when needed
- C. Suggest bereavement counseling
- D. Offer to contact family members
Correct answer: B
Rationale: Encouraging the partner to ask for help when needed is the most appropriate action in this scenario as it promotes healthy coping mechanisms and support during the mourning process. This approach empowers the individual to seek assistance when required, fostering a sense of control and acknowledging the partner's autonomy in dealing with their grief. Avoiding discussing the deceased (Choice A) may hinder the grieving process by suppressing emotions and preventing the partner from expressing their feelings. While suggesting bereavement counseling (Choice C) is important, the immediate support and encouragement to seek help when needed are crucial. Offering to contact family members (Choice D) may not be the most effective step at this stage, as the focus should be on empowering the partner to cope and seek help on their terms.
3. A nurse is teaching a client with diabetes mellitus about foot care. What is the most important instruction the nurse should include?
- A. Apply lotion between the toes after bathing
- B. Inspect feet daily for injuries
- C. Wear shoes only indoors
- D. Cut toenails in a rounded shape
Correct answer: B
Rationale: Inspecting feet daily for injuries is crucial for clients with diabetes to prevent unnoticed wounds from becoming infected. This instruction is the most important as it helps in early detection and management of foot problems. Choice A is incorrect because applying lotion between the toes can lead to excessive moisture, increasing the risk of fungal infections. Choice C is wrong as wearing shoes indoors can also lead to foot issues. Choice D is incorrect because cutting toenails in a rounded shape can result in ingrown toenails, posing a risk for infection.
4. A healthcare professional is reviewing the medical record of a client with a hip fracture. Which finding is a risk factor for pressure injuries?
- A. Frequent repositioning
- B. Poor nutrition
- C. Use of a special mattress
- D. Urinary incontinence
Correct answer: C
Rationale: The correct answer is the use of a special mattress. Special mattresses are designed to reduce pressure on bony prominences, thereby helping to prevent pressure injuries. Frequent repositioning (Choice A) is actually a preventive measure for pressure injuries. Poor nutrition (Choice B) can contribute to delayed wound healing but is not a direct risk factor for pressure injuries. Urinary incontinence (Choice D) can increase the risk of skin breakdown but is not a direct risk factor for pressure injuries.
5. A nurse is updating the plan of care for a client with limited mobility. What intervention should the nurse include to prevent skin breakdown?
- A. Reposition the client every 4 hours
- B. Apply lotion to the skin every 2 hours
- C. Use a special mattress to reduce pressure on the skin
- D. Increase fluid intake to promote skin hydration
Correct answer: C
Rationale: The correct answer is C: 'Use a special mattress to reduce pressure on the skin.' This intervention is crucial in preventing skin breakdown in clients with limited mobility as it helps to reduce pressure on bony prominences. Repositioning every 4 hours (Choice A) is important but may not be sufficient to prevent skin breakdown entirely. Applying lotion every 2 hours (Choice B) may not address the root cause of skin breakdown related to pressure. Increasing fluid intake (Choice D) is beneficial for overall skin health but may not directly prevent skin breakdown caused by pressure points.
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