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PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is preparing to administer 1 unit of packed RBCs to a client. Which of the following findings should cause the nurse to delay the transfusion?
- A. Blood pressure 140/90 mm Hg
- B. Urine output of 40 mL/hr
- C. Temperature 38.2°C (100.8°F)
- D. Hemoglobin 8 g/dL
Correct answer: C
Rationale: A temperature of 38.2°C (100.8°F) suggests the possibility of an underlying infection or fever, which should be evaluated before proceeding with the transfusion to prevent complications. Elevated temperature can indicate an immune response to incompatible blood components, increasing the risk of a transfusion reaction. The other vital signs and lab results provided are within acceptable ranges for administering packed RBCs, making choices A, B, and D less likely to cause a delay in the transfusion.
2. A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
- A. Butterfly rash on the face
- B. Weight gain
- C. Joint deformities
- D. Increased hair growth
Correct answer: A
Rationale: The correct answer is A: Butterfly rash on the face. A butterfly-shaped rash across the nose and cheeks is a classic symptom of systemic lupus erythematosus (SLE), an autoimmune disease. Weight gain (Choice B) is not typically associated with SLE. Joint deformities (Choice C) are more commonly seen in conditions like rheumatoid arthritis. Increased hair growth (Choice D) is not a typical finding in SLE.
3. A healthcare provider is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices should the healthcare provider recommend?
- A. A baked potato
- B. A chicken breast
- C. A banana
- D. A cup of orange juice
Correct answer: B
Rationale: The correct answer is B: A chicken breast. Chicken breast is low in potassium, making it a safe option for clients with chronic kidney disease who need to limit their potassium intake. Foods like bananas and orange juice are high in potassium, which should be avoided or limited by individuals with chronic kidney disease to prevent further kidney damage.
4. A nurse is caring for a client who has a prescription for enalapril. The nurse should monitor the client for which of the following adverse effects of this medication?
- A. Bradycardia
- B. Hyperkalemia
- C. Hyperglycemia
- D. Tinnitus
Correct answer: B
Rationale: The correct answer is B: Hyperkalemia. Enalapril, an ACE inhibitor, can lead to hyperkalemia by reducing aldosterone levels, which results in potassium retention. Bradycardia (Choice A) is not a common adverse effect of enalapril. Hyperglycemia (Choice C) and tinnitus (Choice D) are also not typically associated with enalapril use.
5. A nurse is caring for a client who is taking warfarin. The nurse notes that the client has a new prescription for amoxicillin. Which of the following laboratory tests should the nurse monitor closely?
- A. Serum potassium
- B. Prothrombin time (PT)
- C. Serum sodium
- D. Blood glucose
Correct answer: B
Rationale: The correct answer is B: Prothrombin time (PT). Amoxicillin can potentiate the effects of warfarin, increasing the risk of bleeding. Monitoring the prothrombin time (PT) is crucial in this situation to assess the client's clotting ability. Choices A, C, and D are incorrect because amoxicillin's interaction with warfarin does not directly impact serum potassium, serum sodium, or blood glucose levels.
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