ATI Capstone Fundamental Practice Question with Answers Latest

1. 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) 2. 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) 3. 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) 4. 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) 5. 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) 6. 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)