ATI Capstone Fundamentals Exam 50 Questions and Answers Graded A+

ATI Capstone Fundamentals Exam 50 Questions and Answers Graded A+ a nurse is assessing the pain level of a client who has dementia and difficulty communicating, which pain assessment technique should the nurse use? - behavioral indicators (increased agitation, restlessness) a nurse receives a report from an assistive personnel that a client's BP is 160/95, what should the nurse do first? - recheck the clients BP (reassess prior to any intervention) a nurse is caring for a client who has an indwelling urinary cath, what should the nurse identify as a cath occlusion? - bladder distention (inability to empty the bladder, impaired elimination) 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 of the following types of immunity? - acquired immunity (artificial/acquired immunity occurs when antigens from toxoids or immunizations are ADMINISTERED to a client, once in the body, the stimulate the production of antibodies) a nurse is reviewing the health history of an OA who has a hip fracture the nurse should identify what is a risk of developing pressure injuries? - urinary incontinence (r/f skin breakdown-- pressure injury, poor nutrition, infection, poor tissue perfusion, friction and shear, immobility, alterations in sensory perception) a nurse is assessing the IV infusion site of a client who reports pain at the site. the site is red and there is warmth along the coarse of the vein, what should the nurse do? - d/c the infusion (assessment suggest phlebitis, d/c, apply warm compress//if continued therapy required, start new IV) a nurse is caring for an OA who has a nonpalpable skin lesion that is less than 0.5cm (0.2in) in diameter. which of the following terms should the nurse use to document this finding? - macule (nonpalpable smaller than 1cm, ex: freckle)