ATI Capstone Fundamentals Questions
and Answers 100% Solved
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)
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? ✔✔i
should apply clean dressings over the top of blood saturated dressings and hold pressure
and Answers 100% Solved
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)
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? ✔✔i
should apply clean dressings over the top of blood saturated dressings and hold pressure
