ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is reviewing the health history of a client who has a hip fracture. What risk factor should the nurse identify for developing pressure injuries?
- A. Frequent repositioning
- B. Poor nutrition
- C. Increased fluid intake
- D. Use of a special mattress
Correct answer: B
Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.
2. A nurse is caring for a client who reports pain and burning around the peripheral IV site. What is the nurse's priority action?
- A. Apply a warm compress
- B. Discontinue the IV line
- C. Increase the IV flow rate
- D. Elevate the limb
Correct answer: B
Rationale: The correct answer is B: Discontinue the IV line. When a client reports pain and burning around the peripheral IV site, it indicates possible phlebitis, which is inflammation of the vein. The priority action is to discontinue the IV line to prevent further complications such as infection or thrombosis. Applying a warm compress (Choice A) may worsen the inflammation. Increasing the IV flow rate (Choice C) can exacerbate the symptoms and elevate the risk of complications. Elevating the limb (Choice D) may provide comfort, but it does not address the underlying issue of phlebitis. Therefore, the priority action is to discontinue the IV line.
3. A nurse is caring for a client who reports a decrease in the effectiveness of their arthritis medication. What factor should the nurse identify as contributing to this decrease?
- A. Improved mobility
- B. Bowel inflammation
- C. Long-term use of the medication
- D. Frequent dehydration
Correct answer: B
Rationale: The correct answer is B: Bowel inflammation. Bowel inflammation can decrease the absorption of medications, reducing their effectiveness. Improved mobility (choice A) would generally not contribute to a decrease in medication effectiveness. Long-term use of the medication (choice C) may lead to tolerance but would not directly cause a decrease in effectiveness. Frequent dehydration (choice D) can affect overall health but is not a direct factor in the medication's effectiveness for arthritis.
4. A client with chronic obstructive pulmonary disease (COPD) is being taught breathing exercises by a nurse. What instruction should the nurse include to improve oxygenation?
- A. Use pursed-lip breathing during activities
- B. Use deep breathing exercises after meals
- C. Perform diaphragmatic breathing during exercise
- D. Breathe in short, shallow breaths
Correct answer: A
Rationale: The correct instruction the nurse should include to improve oxygenation for a client with COPD is to 'Use pursed-lip breathing during activities.' Pursed-lip breathing helps improve oxygenation by slowing down the respiratory rate, reducing the work of breathing, and keeping the airways open. This technique also helps prevent the collapse of small airways during exhalation, allowing for more complete emptying of the lungs. Choices B, C, and D are incorrect because deep breathing exercises after meals, diaphragmatic breathing during exercise, and breathing in short, shallow breaths do not specifically target the improvement of oxygenation in individuals with COPD.
5. A nurse is planning a community education program about colorectal cancer. What risk factors should the nurse identify as modifiable?
- A. Age and gender
- B. High-fat diet, smoking, alcohol consumption
- C. Ethnicity and race
- D. Exposure to radiation
Correct answer: B
Rationale: The correct answer is B: High-fat diet, smoking, alcohol consumption. These are modifiable risk factors for colorectal cancer as individuals can make lifestyle changes to reduce their risk. Age and gender (choice A) are non-modifiable risk factors. Ethnicity and race (choice C) can influence the risk of colorectal cancer but are not modifiable factors. Exposure to radiation (choice D) is not a common modifiable risk factor for colorectal cancer.
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