ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3 days. What lab result indicates the client is experiencing fluid volume deficit (FVD)?
- A. Decreased BUN levels
- B. Increased hematocrit
- C. Increased white blood cell count
- D. Decreased hematocrit
Correct answer: B
Rationale: The correct answer is B: Increased hematocrit. Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. When there is a decrease in fluid volume in the body, the blood becomes more concentrated, leading to an increase in hematocrit levels. Choices A, C, and D are incorrect because decreased BUN levels, increased white blood cell count, and decreased hematocrit are not indicative of fluid volume deficit.
2. A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?
- A. Increase the IV flow rate
- B. Discontinue the infusion
- C. Elevate the limb
- D. Apply a cold compress
Correct answer: B
Rationale: The correct answer is to discontinue the infusion (Choice B) as the signs described suggest phlebitis, an inflammation of the vein. Increasing the IV flow rate (Choice A) can exacerbate the condition by increasing the irritation. Elevating the limb (Choice C) and applying a cold compress (Choice D) are not the appropriate interventions for phlebitis. Elevation and cold therapy are more suitable for conditions like swelling or inflammation, but in this case, discontinuing the infusion is the priority to prevent further complications.
3. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. What food should the nurse instruct the client to avoid?
- A. Steamed carrots
- B. Mashed potatoes
- C. Orange slices
- D. Soft-cooked eggs
Correct answer: C
Rationale: The correct answer is C: Orange slices. For a client on a mechanical soft diet, foods that are difficult to chew and swallow should be avoided. Orange slices have membranes that can be challenging to consume for individuals with swallowing difficulties. Steamed carrots (Choice A) and mashed potatoes (Choice B) are typically suitable for a mechanical soft diet as they can be easily mashed or cut into smaller pieces. Soft-cooked eggs (Choice D) are also appropriate for this diet as they are soft and easy to chew.
4. A healthcare professional is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. What finding should the healthcare professional expect?
- A. Decreased respiratory rate
- B. Flushing of the skin
- C. Flaring of the nostrils
- D. Productive cough
Correct answer: C
Rationale: Flaring of the nostrils is a sign of increased respiratory effort, which is common in clients with COPD experiencing dyspnea. Choices A, B, and D are incorrect. A decreased respiratory rate is not expected in a client with COPD experiencing dyspnea, as they often have an increased respiratory rate. Flushing of the skin is not a typical finding associated with COPD or dyspnea. While a productive cough can be seen in COPD, it is not specifically related to the increased respiratory effort seen with dyspnea.
5. A client signed an informed consent form for surgery but has expressed doubts about the need for surgery. What should the nurse say?
- A. Reassure the client of the surgeon's skill
- B. The surgeon will answer your questions before surgery
- C. Tell the client surgery is necessary
- D. Encourage the client to seek a second opinion
Correct answer: B
Rationale: The correct answer is B because the surgeon should address the client's doubts before surgery. Informed consent requires that the client fully understands the procedure. Choice A is incorrect because reassuring the client of the surgeon's skill does not address the client's doubts about the need for surgery. Choice C is incorrect because telling the client surgery is necessary may not address their concerns and could violate the principle of autonomy. Choice D is incorrect as the immediate concern is addressing the client's doubts before surgery, not necessarily seeking a second opinion.
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