ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A client with diabetes mellitus is being taught about the importance of foot care by a nurse. Which instruction should the nurse include?
- A. Cut toenails straight across
- B. Wear shoes at all times
- C. Soak feet in hot water daily
- D. Apply lotion between the toes
Correct answer: B
Rationale: The correct answer is B: 'Wear shoes at all times.' Clients with diabetes are at a higher risk of foot complications due to poor circulation and nerve damage. Wearing shoes at all times helps protect their feet from injuries. Choice A is incorrect because toenails should be cut straight across to prevent ingrown toenails. Choice C is incorrect as soaking feet in hot water can lead to burns or skin damage, especially for those with diabetes who may have reduced sensation. Choice D is incorrect because applying lotion between the toes can create a moist environment, increasing the risk of fungal infections.
2. 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.
3. A nurse is monitoring a client who is receiving continuous enteral feedings. What finding suggests the client is not tolerating the feeding?
- A. Increased bowel sounds
- B. Nausea
- C. Elevated blood pressure
- D. Fever
Correct answer: B
Rationale: Nausea is a common sign indicating that the client is not tolerating enteral feedings well. It can be a result of various issues such as feeding intolerance, infection, or other underlying conditions. Nausea should be promptly addressed to prevent further complications. Increased bowel sounds (Choice A) are not typically indicative of feeding intolerance. Elevated blood pressure (Choice C) and fever (Choice D) are generally not directly related to enteral feeding intolerance unless there are specific underlying conditions contributing to them.
4. A nurse is teaching about food choices for a client on a low-sodium diet. What food should the nurse recommend?
- A. Canned soup
- B. Fresh fruit
- C. Processed meats
- D. Frozen meals
Correct answer: B
Rationale: Fresh fruit is a good option for clients on a low-sodium diet as it is naturally low in sodium. Canned soup, processed meats, and frozen meals tend to be high in sodium due to added salt and preservatives, making them unsuitable choices for individuals on a low-sodium diet.
5. A nurse is caring for a client who is postoperative following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased physical activity
- B. Frequent urge suppression
- C. Adequate sleep
- D. Increased fluid intake
Correct answer: B
Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt the normal bowel movement pattern and lead to constipation. Choices A, C, and D are behaviors that generally help prevent constipation rather than increase the risk. Increased physical activity, adequate sleep, and increased fluid intake promote bowel regularity and reduce the risk of constipation.
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