ATI RN
ATI Capstone Fundamentals Assessment Proctored Questions
Question 1 of 5
A healthcare provider is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare provider use?
Correct Answer: C
Rationale: In clients with dementia and difficulty communicating, using behavioral indicators such as agitation and restlessness is more reliable for assessing pain than relying on verbal self-report, pain scales, or observing facial expressions. Verbal self-report may not be possible due to communication challenges, pain scales may be difficult for the client to comprehend, and observing facial expressions alone may not provide a comprehensive assessment of pain in individuals with dementia.
Question 2 of 5
A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?
Correct Answer: B
Rationale: The correct answer is B: Bladder distention. Bladder distention is a sign of catheter occlusion because it indicates a failure to drain urine properly. Bladder spasms (Choice A) are more commonly associated with bladder irritability rather than catheter occlusion. Frequent urination (Choice C) is unlikely in a client with an indwelling catheter as the urine should be draining continuously. Hematuria (Choice D) refers to blood in the urine and is not typically a direct sign of catheter occlusion.
Question 3 of 5
A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?
Correct Answer: B
Rationale: An immunization functions as part of acquired immunity. Acquired immunity involves the production of antibodies after immunization, which helps protect against future infections. Natural immunity is not induced by immunization but is present from birth. Passive immunity is temporary and acquired through the transfer of pre-formed antibodies. Cell-mediated immunity is a type of immune response that involves the activation of phagocytes, antigen-specific cytotoxic T-lymphocytes, and the release of various cytokines in response to an antigen.
Question 4 of 5
When reviewing the health history of an older adult with a hip fracture, what should a nurse identify as a risk factor for developing pressure injuries?
Correct Answer: C
Rationale: Urinary incontinence is a risk factor for skin breakdown, which can lead to the development of pressure injuries. While malnutrition, poor hygiene, and immobility are important considerations in overall patient care, they are not specifically identified as significant risk factors for pressure injuries in this scenario.
Question 5 of 5
While assessing the IV infusion site of a client experiencing pain, redness, and warmth, what should the nurse do?
Correct Answer: B
Rationale: The correct answer is to discontinue the infusion. Pain, redness, and warmth at the IV site are signs of phlebitis, which is inflammation of the vein. Continuing the infusion can further irritate the vein and lead to complications. Increasing the IV flow rate would exacerbate the issue by delivering more irritants to the vein. Elevating the limb and applying a cold compress are not the appropriate interventions for phlebitis, as discontinuing the infusion is crucial to prevent further harm.