ATI Capstone Proctored Fundamentals
questions and answers 2024\2025 A+
Grade
a nurse is assessing the pain level of a client who has dementia and difficulty communicating, which pain
assessment technique should the nurse use?
- correct answer 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?
- correct answer 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?
- correct answer 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?
- correct answer 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?
- correct answer 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?
- correct answer 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?
- correct answer macule
(nonpalpable smaller than 1cm, ex: freckle)
a community health nurse is teaching a group of clients about first aid for different types of wounds.
which of the following client statements indicates an understanding of the teaching?
- correct answer i should apply clean dressings over the top of blood saturated dressings and hold
pressure
(to prevent disruption of wound tissue)
a nurse is sitting with the partner of a client who recently died. which of the following actions should the
nurse take to facilitate mourning?
- correct answer encourage the partner to ask for help when needed
a nurse is in an acute care facility is caring for a client who is postop following abdominal surgery. which
of the following behaviors should the nurse identify as increasing the client's risk for constipation?
- correct answer urge suppression
history of chronic stimulant laxative use
questions and answers 2024\2025 A+
Grade
a nurse is assessing the pain level of a client who has dementia and difficulty communicating, which pain
assessment technique should the nurse use?
- correct answer 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?
- correct answer 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?
- correct answer 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?
- correct answer 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?
- correct answer 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?
- correct answer 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?
- correct answer macule
(nonpalpable smaller than 1cm, ex: freckle)
a community health nurse is teaching a group of clients about first aid for different types of wounds.
which of the following client statements indicates an understanding of the teaching?
- correct answer i should apply clean dressings over the top of blood saturated dressings and hold
pressure
(to prevent disruption of wound tissue)
a nurse is sitting with the partner of a client who recently died. which of the following actions should the
nurse take to facilitate mourning?
- correct answer encourage the partner to ask for help when needed
a nurse is in an acute care facility is caring for a client who is postop following abdominal surgery. which
of the following behaviors should the nurse identify as increasing the client's risk for constipation?
- correct answer urge suppression
history of chronic stimulant laxative use
