ATI RN
ATI Capstone Fundamentals Assessment Proctored Questions
Question 1 of 5
A nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter. What is the nurse's first action?
Correct Answer: B
Rationale: The correct first action for the nurse to take when a client reports pain and tenderness at the site of an indwelling urinary catheter is to notify the provider. Pain and tenderness at the catheter site may indicate infection, and the healthcare provider needs to be informed for further assessment and appropriate interventions. Irrigating the catheter with normal saline (
Choice
A) should not be the initial action without consulting the provider first. While assessing for signs of infection (
Choice
C) is important, notifying the provider takes precedence. Administering prescribed antibiotics (
Choice
D) should only be done based on the provider's orders after assessment and confirmation of infection.
Question 2 of 5
A client is being taught how to use a cane. Which instruction should the nurse include?
Correct Answer: A
Rationale: The correct answer is to use the cane on the stronger side. This instruction is important because it provides better support and balance. Placing the cane on the stronger side helps to shift weight off the weaker or injured side, reducing the risk of falls and promoting stability.
Choices B, C, and D are incorrect. Using the cane on the weaker side would not provide optimal support. While ensuring the cane has a rubber tip and holding it 1-2 inches from the ground are important, they are not as crucial as using the cane on the stronger side for proper support and balance.
Question 3 of 5
A nurse is reviewing a client's health history and identifies chronic constipation as a potential complication of immobility. What intervention should the nurse include in the plan of care?
Correct Answer: A
Rationale: Increasing fiber intake is the appropriate intervention to include in the plan of care for a client with chronic constipation due to immobility. Fiber helps add bulk to the stool, making it easier to pass, thereby preventing constipation. Encouraging the client to walk daily (choice
B) is also beneficial as it promotes mobility and can help alleviate constipation associated with immobility. Using a stool softener as needed (choice
C) and using a laxative daily (choice
D) are not the first-line interventions for managing constipation related to immobility. Stool softeners and laxatives should be used judiciously and under healthcare provider guidance.
Question 4 of 5
A client has a new prescription for a metered-dose inhaler (MDI). What instruction should the nurse include?
Correct Answer: C
Rationale: The correct instruction for a client using a metered-dose inhaler (MDI) is to hold the inhaler 1-2 inches from the mouth. This distance allows for the proper delivery of the medication into the lungs.
Choice A is incorrect because the duration of inhalation can vary depending on the medication, and 1 second may not be adequate.
Choice B is incorrect as shaking the inhaler vigorously is not necessary for all MDIs and can lead to inaccurate dosing.
Choice D is incorrect as the client should hold their breath for about 10 seconds after inhalation to allow the medication to deposit in the lungs.
Question 5 of 5
A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. Which term should the nurse use to document this finding?
Correct Answer: B
Rationale: The correct answer is B: Macule. A macule is a flat, nonpalpable skin lesion that is smaller than 1 cm in diameter. In this case, the lesion is less than 0.5cm, fitting the description of a macule. A papule (choice
A) is a solid, elevated lesion less than 0.5 cm in diameter. A nodule (choice
C) is a solid, elevated lesion that is 0.5 cm or larger in diameter. A tumor (choice
D) refers to a mass of abnormal tissue growth, which is not applicable in this scenario.