ATI RN
ATI Capstone Fundamentals Assessment Proctored
1. A client with diabetes mellitus is being taught about foot care by a nurse. Which statement indicates understanding?
- A. I will soak my feet in hot water daily
- B. I will wear my slippers whenever I am out of bed
- C. I should apply lotion between my toes after washing my feet
- D. I will cut my nails in a rounded shape
Correct answer: B
Rationale: The correct answer is B. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it helps prevent injuries to the feet, reducing the risk of infection. Choices A, C, and D are incorrect. Soaking feet in hot water daily can lead to dryness and skin damage, applying lotion between toes can create a moist environment promoting fungal growth, and cutting nails in a rounded shape can increase the risk of ingrown nails.
2. A nurse is reviewing a client's health history and identifies a history of pressure injuries. What intervention should the nurse include in the plan of care?
- A. Reposition the client every 4 hours
- B. Apply a moisture-retentive dressing
- C. Apply a heating pad to the site
- D. Keep the client on bedrest
Correct answer: B
Rationale: The correct intervention for a client with pressure injuries is to apply a moisture-retentive dressing. This type of dressing helps create a moist wound environment, which is conducive to healing. Repositioning the client every 4 hours is important to prevent further pressure injuries, but it is not the primary intervention for existing pressure injuries. Applying a heating pad to the site can increase the risk of tissue damage and is contraindicated for pressure injuries. Keeping the client on bedrest can lead to further complications and delayed healing of pressure injuries.
3. A client with a new diagnosis of diabetes mellitus is being taught about foot care. What instruction should the nurse include?
- A. Apply lotion between the toes after bathing
- B. Wear shoes at all times
- C. Cut toenails in a rounded shape
- D. Inspect the feet weekly
Correct answer: B
Rationale: The correct answer is to wear shoes at all times. This instruction is vital for clients with diabetes mellitus as it helps protect the feet and reduces the risk of injury. Option A is incorrect as applying lotion between the toes can increase moisture and the risk of fungal infections. Option C is incorrect as cutting toenails in a rounded shape may lead to ingrown toenails. Option D is also incorrect as inspecting the feet weekly is not sufficient for proper foot care in clients with diabetes mellitus.
4. While documenting client care, which entry should the nurse identify as an example of implementing client care?
- A. Documenting the client's pain level
- B. Monitoring the client's urine output
- C. Assessing the client's range of motion
- D. Contacting the provider to report client findings
Correct answer: D
Rationale: The correct answer is D because contacting the provider to report client findings is an example of implementing care. Implementation involves putting the care plan into action based on assessment data. While options A, B, and C are important aspects of client care, they mainly focus on assessment rather than the actual implementation of care.
5. A nurse is providing discharge teaching to a client with a new diagnosis of hypertension. What lifestyle modification should the nurse emphasize?
- A. Decrease potassium intake
- B. Increase fluid intake to 2 liters per day
- C. Avoid foods high in calcium
- D. Increase sodium intake
Correct answer: B
Rationale: The correct lifestyle modification that the nurse should emphasize for a client with hypertension is to increase fluid intake to 2 liters per day. Proper hydration helps manage hypertension by supporting kidney function in regulating blood pressure and by diluting sodium levels in the body. Decreasing potassium intake (Choice A) is not recommended, as potassium-rich foods like fruits and vegetables are beneficial for blood pressure control. Avoiding foods high in calcium (Choice C) is not directly related to managing hypertension, and increasing sodium intake (Choice D) is contraindicated as excess sodium can elevate blood pressure.
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