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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is planning care for a client who has chronic renal failure. Which action should the nurse include in the plan of care?
- A. Encourage increased fluid intake
- B. Restrict protein intake to the RDA
- C. Increase dietary potassium
- D. Encourage foods high in sodium
Correct answer: B
Rationale: The correct action the nurse should include in the plan of care for a client with chronic renal failure is to restrict protein intake to the RDA. This is important because limiting protein helps reduce the buildup of waste products that the kidneys are unable to efficiently excrete. Encouraging increased fluid intake (choice A) may further burden the kidneys, increasing the risk of fluid overload. Increasing dietary potassium (choice C) is not recommended in chronic renal failure as impaired kidneys have difficulty regulating potassium levels. Encouraging foods high in sodium (choice D) is also not appropriate as excessive sodium intake can lead to fluid retention and hypertension, which are detrimental in renal failure.
2. A postpartum client with AB negative blood whose newborn is B positive requires what intervention?
- A. Administer Rh immune globulin within 72 hours of delivery
- B. Administer Rh immune globulin at the 6-week postpartum visit
- C. No Rh immune globulin is needed since this is the second pregnancy
- D. Both mother and baby need Rh immune globulin
Correct answer: A
Rationale: The correct intervention is to administer Rh immune globulin within 72 hours of delivery. This is essential to prevent the mother from forming antibodies against Rh-positive blood, which could cause complications in future pregnancies. Choice B is incorrect as the administration should be immediate postpartum. Choice C is incorrect as Rh immune globulin is needed for each Rh-incompatible pregnancy. Choice D is incorrect as only the mother, who is Rh-negative, needs Rh immune globulin.
3. A nurse is reviewing the ABG results of a client with chronic emphysema. Which result suggests the need for further treatment?
- A. PaO2 level of 89 mm Hg
- B. PaCO2 level of 55 mm Hg
- C. HCO3 level of 25 mEq/L
- D. pH level of 7.37
Correct answer: B
Rationale: The correct answer is B. A PaCO2 level of 55 mm Hg is elevated, indicating carbon dioxide retention, a common complication of emphysema that necessitates intervention. Elevated PaCO2 can lead to respiratory acidosis, reflecting inadequate ventilation. Choices A, C, and D are within normal ranges. A PaO2 level of 89 mm Hg is acceptable. An HCO3 level of 25 mEq/L falls within the normal range, suggesting adequate compensation. A pH level of 7.37 is also within the normal range, indicating the client's acid-base balance is maintained.
4. A nurse is planning care for four clients. Which client is the highest priority?
- A. Client with dry, black eschar on the heel
- B. Client wearing an arm cast and reporting numb fingers
- C. Client with reddened skin around the coccyx
- D. Client with frequent incontinence
Correct answer: B
Rationale: The correct answer is B because numb fingers indicate neurovascular compromise, which can lead to serious complications if not addressed promptly. The priority in this situation is to assess and address any circulation issues affecting the extremity. Choices A, C, and D are of concern but not as immediate as neurovascular compromise, which requires urgent attention to prevent further complications.
5. A client is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?
- A. Respiratory rate of 12/min
- B. Diminished deep tendon reflexes
- C. Urine output 40 mL/hr
- D. Systolic blood pressure of 140 mm Hg
Correct answer: B
Rationale: Diminished deep tendon reflexes are a sign of magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to decreased reflexes. Respiratory rate of 12/min, urine output 40 mL/hr, and systolic blood pressure of 140 mm Hg are not specific findings of magnesium toxicity. Respiratory depression, oliguria, and hypotension are more concerning signs that require immediate attention.
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