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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is providing teaching to a client with a new diagnosis of diabetes mellitus. Which instruction should the nurse give to the client to monitor for hypoglycemia?
- A. Monitor for polyuria
- B. Monitor for diaphoresis
- C. Monitor for abdominal pain
- D. Monitor for thirst
Correct answer: B
Rationale: The correct answer is B: 'Monitor for diaphoresis.' Diaphoresis, which refers to excessive sweating, is a common symptom of hypoglycemia. It indicates a low blood sugar level and should prompt immediate treatment. Polyuria (excessive urination), abdominal pain, and thirst are not typically associated with hypoglycemia. Polyuria is more commonly linked to hyperglycemia, while abdominal pain and thirst are not specific symptoms of hypoglycemia.
2. A nurse is assessing a client with pericarditis. Which of the following findings is the priority for the nurse to report?
- A. Paradoxical pulse
- B. Dependent edema
- C. Pericardial friction rub
- D. Substernal chest pain
Correct answer: A
Rationale: A paradoxical pulse is a sign of cardiac tamponade, a life-threatening complication of pericarditis that requires immediate intervention. It results from decreased cardiac output due to increased pressure in the pericardial sac. Reporting this finding promptly allows for timely treatment to prevent further deterioration. Dependent edema and substernal chest pain are common in pericarditis but are not as urgent as a paradoxical pulse. A pericardial friction rub is a classic finding in pericarditis and indicates inflammation but is not as critical as a paradoxical pulse.
3. A nurse is preparing to administer furosemide to a client who has a prescription. Which of the following statements by the client indicates a need for further teaching?
- A. I will take my morning pills with food or milk.
- B. I will weigh myself every day.
- C. I will notify the nurse if I have muscle cramps.
- D. I will limit my intake of fish.
Correct answer: D
Rationale: The correct answer is D. There is no need to limit fish intake with furosemide, indicating a misunderstanding of dietary restrictions. Furosemide is a diuretic that helps the body get rid of excess water and salt. Choices A, B, and C are all appropriate actions for a client taking furosemide. Taking morning pills with food or milk can help reduce stomach upset, weighing oneself daily helps monitor fluid retention, and notifying the nurse about muscle cramps can be important due to potential electrolyte imbalances.
4. A client in respiratory distress who is on oxygen is being cared for by a nurse. What is the most appropriate short-term goal?
- A. Nasal cannula remains in place
- B. Client completes morning care
- C. Client verbalizes breathing improvement after lunch
- D. Client maintains oxygen saturation of 90% during the shift
Correct answer: D
Rationale: The correct answer is D because maintaining oxygen saturation of 90% is a specific, measurable short-term goal that ensures adequate oxygenation. Choice A is not a goal focused on the client's physiological status but rather on the equipment. Choice B is related to activities of daily living and does not address the respiratory distress issue. Choice C is subjective and may not reflect the actual physiological improvement in the client's condition.
5. A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?
- A. Take vital signs
- B. Assess lochia
- C. Massage the fundus
- D. Give oxytocin IV bolus
Correct answer: C
Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.
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