ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is providing discharge teaching for a client with a prescription for home oxygen therapy. Which instruction should the nurse include?
- A. Increase the oxygen flow rate when shortness of breath occurs
- B. Keep oxygen tubing away from heat sources
- C. Wear synthetic fabrics to prevent static
- D. Turn off the oxygen when not in use
Correct answer: B
Rationale: The correct instruction for a client with home oxygen therapy is to keep oxygen tubing away from heat sources to prevent fires and other hazards. Option A is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Option C is incorrect as synthetic fabrics can generate static electricity, which is a fire hazard. Option D is incorrect as oxygen should be left on as prescribed unless advised otherwise.
2. A nurse is assessing a client who is at risk for pressure injuries. Which intervention should the nurse include in the plan of care?
- A. Reposition the client every 4 hours
- B. Use a special mattress for the client
- C. Keep the client on bedrest
- D. Encourage the client to remain in one position
Correct answer: B
Rationale: The correct answer is B: 'Use a special mattress for the client.' Using a special mattress reduces pressure on bony prominences and helps prevent pressure injuries. Repositioning the client every 4 hours (choice A) is important but using a special mattress is more effective. Keeping the client on bedrest (choice C) can increase the risk of pressure injuries due to prolonged immobility. Encouraging the client to remain in one position (choice D) is incorrect as it can lead to pressure injuries by exerting pressure on the same areas for an extended period.
3. 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.
4. A nurse is preparing to administer a medication through a nasogastric (NG) tube. What action should the nurse take first?
- A. Flush the NG tube with 60 mL of water
- B. Verify tube placement
- C. Crush the medications and dissolve them in water
- D. Administer all medications together
Correct answer: B
Rationale: Verifying tube placement is the priority before administering any medications through a nasogastric tube. This step ensures that the tube is correctly positioned in the stomach to prevent complications such as aspiration. Flushing the tube with water, crushing medications, or administering them together should only be done after confirming the correct placement of the NG tube. Therefore, option B is the correct first action to take in this scenario.
5. A nurse receives a report from assistive personnel that a client's BP is 160/95. What should the nurse do first?
- A. Notify the provider
- B. Recheck the blood pressure
- C. Administer antihypertensive medication
- D. Document the blood pressure in the chart
Correct answer: B
Rationale: The correct first action for the nurse to take when receiving a report of a client's blood pressure reading of 160/95 is to recheck the blood pressure. Rechecking the blood pressure ensures the accuracy of the reading before making any further decisions or interventions. Notifying the provider (Choice A) can be considered after confirming the blood pressure reading. Administering antihypertensive medication (Choice C) should not be done based solely on one reading without verification. Documenting the blood pressure in the chart (Choice D) should also come after confirming the accuracy of the reading to avoid recording incorrect information.
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