ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A nurse is teaching a client about ways to reduce the risk of deep vein thrombosis (DVT) after surgery. What should the nurse include in the teaching?
- A. Rest in bed for long periods
- B. Use sequential compression devices
- C. Avoid leg exercises
- D. Keep legs crossed
Correct answer: B
Rationale: The correct answer is to 'Use sequential compression devices.' Sequential compression devices help prevent DVT by promoting venous return, reducing stasis in the veins, and preventing blood clot formation. Resting in bed for long periods (Choice A) can actually increase the risk of DVT due to decreased mobility. Avoiding leg exercises (Choice C) is also not recommended as mobilization and exercises can help prevent blood clots. Keeping legs crossed (Choice D) can impede blood flow and is not advisable in reducing the risk of DVT.
2. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which client statement indicates an understanding of the teaching?
- A. Apply pressure directly to the wound
- B. Remove the dressings to assess the wound
- C. Use a clean dressing over the saturated one
- D. Apply alcohol to the wound
Correct answer: C
Rationale: The correct answer is C because placing a clean dressing over the saturated one helps maintain wound integrity and prevents further tissue damage. Choice A is incorrect as applying direct pressure to the wound is correct for controlling bleeding but not for dressing changes. Choice B is incorrect because removing dressings may disrupt wound healing and increase the risk of infection. Choice D is incorrect since applying alcohol to the wound can cause further irritation and damage to the tissues.
3. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What instruction should the nurse include?
- A. Reduce sodium intake to 4 grams per day
- B. Avoid foods high in potassium
- C. Take prescribed antihypertensive medications daily
- D. Limit fluid intake to 1 liter per day
Correct answer: C
Rationale: The correct answer is C: 'Take prescribed antihypertensive medications daily.' When providing discharge teaching to a client with hypertension, one of the key instructions is to ensure the consistent intake of prescribed antihypertensive medications. This is crucial for controlling blood pressure levels and reducing the risk of complications associated with hypertension. Choices A, B, and D are incorrect because reducing sodium intake, avoiding foods high in potassium, and limiting fluid intake are important dietary modifications for various health conditions, but they are not the priority when it comes to managing hypertension. The primary focus should be on medication adherence to effectively manage hypertension.
4. A nurse is planning to administer multiple medications to a client with dysphagia. What action should the nurse take?
- A. Crush medications and mix them with honey
- B. Provide medications through a straw
- C. Place the medications in small amounts of pudding
- D. Offer the medications with a full glass of water
Correct answer: C
Rationale: The correct action for the nurse to take when administering medications to a client with dysphagia is to place the medications in small amounts of pudding. Mixing medications with pudding helps clients with dysphagia swallow them more easily. Choice A (crushing medications and mixing with honey) is not recommended as it may alter the medication properties. Choice B (providing medications through a straw) is not suitable for clients with dysphagia as it can pose a choking hazard. Choice D (offering medications with a full glass of water) may be difficult for clients with dysphagia to swallow and increase the risk of aspiration.
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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