ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A healthcare professional is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the professional include?
- A. Inhale for 1 second
- B. Shake the inhaler vigorously
- C. Hold the inhaler 5-7 cm away from the mouth
- D. Hold breath for 5 seconds after inhalation
Correct answer: B
Rationale: The correct instruction when using a metered-dose inhaler (MDI) is to shake the inhaler vigorously before use. Shaking the inhaler ensures proper mixing of the medication, which is crucial for effective delivery of the medication into the lungs. Inhaling for a specific duration, holding the inhaler at a certain distance from the mouth, or holding the breath after inhalation are not as critical as ensuring proper mixing of the medication by shaking the inhaler.
2. When performing an abdominal assessment on a client, what action should the nurse take first?
- A. Palpate the abdomen
- B. Auscultate bowel sounds
- C. Inspect the abdomen
- D. Percuss the abdomen
Correct answer: B
Rationale: The correct answer is to auscultate bowel sounds. This action should be taken first because it ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen (choice C) may provide visual cues but does not address functional assessment. Palpating the abdomen (choice A) should follow auscultation to prevent altering bowel sounds. Percussing the abdomen (choice D) is typically done after auscultation and palpation.
3. A client with diabetes mellitus is being taught about foot care by a nurse. Which instruction should the nurse include?
- A. Cut toenails straight across
- B. Wear shoes at all times
- C. Apply lotion between the toes
- D. Soak feet in hot water daily
Correct answer: B
Rationale: The correct answer is to 'Wear shoes at all times.' This instruction is crucial for preventing foot injuries in clients with diabetes mellitus. Wearing shoes protects the feet from potential injuries and reduces the risk of developing foot ulcers. Cutting toenails straight across (not in a rounded shape) helps prevent ingrown toenails. Applying lotion between the toes can create a moist environment, increasing the risk of fungal infections. Soaking feet in hot water daily can lead to dry skin and potentially cause burns, which is not recommended for individuals with diabetes.
4. A healthcare professional is reviewing the lab results of a client who has been experiencing a fever for 3 days. What finding indicates fluid volume deficit (FVD)?
- A. Decreased hematocrit
- B. Increased white blood cell count
- C. Increased hematocrit
- D. Decreased white blood cell count
Correct answer: C
Rationale: Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. In FVD, there is a loss of fluid without a proportional loss of electrolytes, leading to hemoconcentration. Choices A, B, and D are incorrect. Decreased hematocrit and decreased white blood cell count are not typical findings in fluid volume deficit. An increased white blood cell count is more indicative of infection or inflammation rather than fluid volume deficit.
5. A nurse receives a report from an assistive personnel that a client's BP is 160/95. What should the nurse do first?
- A. Administer antihypertensive medication
- B. Notify the healthcare provider
- C. Recheck the blood pressure
- D. Document the blood pressure in the chart
Correct answer: C
Rationale: The correct first action for the nurse in this scenario is to recheck the blood pressure. This step is crucial to confirm the accuracy of the initial reading. Administering antihypertensive medication without verifying the blood pressure could lead to inappropriate treatment. Notifying the healthcare provider can be done after ensuring the accuracy of the reading. Simply documenting the blood pressure without validation may result in acting on potentially incorrect information. Therefore, the priority is to recheck the blood pressure.
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