ATI Capstone Fundamentals Assessment Proctored

Correct Answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Nausea can indicate various issues such as feeding intolerance, formula composition problems, or underlying medical conditions. Decreased heart rate, fever, and weight gain are not typical signs of feeding intolerance. Decreased heart rate and fever may indicate other medical conditions, while weight gain is not an immediate sign of intolerance to enteral feedings.

Correct Answer: B

Rationale: Corrected Rationale: Poor nutrition increases the risk of developing pressure injuries as it impairs skin integrity and healing. Frequent repositioning, increased fluid intake, and the use of a special mattress are all important interventions for preventing pressure injuries, rather than risk factors for developing them. Repositioning helps relieve pressure, adequate fluid intake maintains skin hydration, and special mattresses redistribute pressure to prevent injuries.

Correct Answer: B

Rationale: In the event of a fire, the priority is to ensure everyone's safety. Therefore, the nurse's initial action should be to evacuate the room. Calling for assistance can be done while evacuating, ensuring help is on the way. Attempting to put out the fire can be dangerous and may delay evacuation. Turning off the oxygen supply is not the first step in this situation, as the immediate concern is to remove individuals from the potential danger.

Correct Answer: A

Rationale: Nausea is a common symptom of intolerance to enteral feedings. When a client experiences nausea during enteral feeding, it can indicate issues such as feeding tube placement problems, formula intolerance, or gastroparesis. Nausea can lead to vomiting and further complications if not addressed promptly. Decreased heart rate, weight gain, and fever are not typically associated with intolerance to enteral feedings and would not be the primary indicators for this situation.

Correct Answer: B

Rationale: Nausea is a common sign of intolerance to enteral feedings and should be addressed promptly. Weight gain is not typically associated with intolerance to enteral feedings; instead, it may indicate other issues such as fluid retention. Constipation is also not a direct indicator of intolerance to enteral feedings. While an elevated heart rate can occur for various reasons, it is less specific to enteral feeding intolerance compared to nausea.