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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is teaching a client with mild persistent asthma who has been prescribed montelukast. Which statement by the nurse is appropriate?
- A. This medication can be used during an acute asthma attack.
- B. This medication should be taken before exercise.
- C. You can take this medication for 10 days, then discontinue.
- D. This medication helps decrease swelling and mucus production.
Correct answer: D
Rationale: The correct answer is D: 'This medication helps decrease swelling and mucus production.' Montelukast is used for long-term asthma management as it helps reduce inflammation and mucus production in the airways. It is not appropriate for acute asthma attacks. Choice A is incorrect because montelukast is not a rescue medication for acute attacks. Choice B is incorrect because montelukast is not specifically taken before exercise. Choice C is incorrect because montelukast is usually taken regularly, not just for a short duration.
2. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?
- A. Sunken anterior fontanel
- B. Tenting skin turgor
- C. Flat anterior fontanel
- D. Hyperpnea
Correct answer: C
Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.
3. A nurse is caring for a 7-month-old infant being treated for severe dehydration. Which finding indicates treatment has been effective?
- A. Skin turgor displays tenting
- B. Flat anterior fontanel
- C. Cool, mottled skin
- D. Hyperpnea
Correct answer: B
Rationale: A flat anterior fontanel indicates improved hydration in infants, as dehydration typically causes sunken fontanels.
4. 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.
5. A nurse is providing teaching for a client who is prescribed enoxaparin for DVT prevention. What is an appropriate action by the nurse?
- A. Expel the air bubble from the prefilled syringe
- B. Massage the injection site to distribute the medication
- C. Inject the medication into the lateral abdominal wall
- D. Administer an NSAID for injection site discomfort
Correct answer: C
Rationale: The correct action for a nurse when administering enoxaparin for DVT prevention is to inject the medication into the lateral abdominal wall. This is the recommended site for enoxaparin administration. Expelling the air bubble is unnecessary and may lead to a dosage error. Massaging the injection site is not recommended as it can cause bruising. Administering an NSAID for injection site discomfort is not necessary as discomfort should be minimal and transient.
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