a home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor what interve
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN

1. A home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor. What intervention should the nurse include in the teaching?

Correct answer: C

Rationale: The correct intervention the nurse should include in the teaching is to pad the side rails of the bed. By padding the side rails, the nurse can help prevent injury if the patient experiences a seizure. Administering antiseizure medications promptly (Choice A) is typically the responsibility of a healthcare provider or according to a prescribed schedule. Using oral airway devices during seizures (Choice B) can pose risks and should be managed by healthcare professionals. Applying restraints during a seizure (Choice D) is not recommended as it can lead to further injury and complications.

2. A charge nurse is planning care for a group of patients on a med-surg unit. What task should the nurse delegate to an assistive personnel?

Correct answer: A

Rationale: The correct answer is A because assistive personnel can be assigned to measure and document urinary output, a routine task within their scope of practice. Administering medications (choice B) requires a higher level of training and should be done by licensed nurses. Reinforcing patient education (choice C) involves providing information and ensuring patient understanding, which is typically done by licensed healthcare providers. Initiating a care plan (choice D) involves critical thinking and assessment skills, which are beyond the scope of practice for assistive personnel.

3. While receiving a change of shift report on a group of clients, which patient should the nurse assess first?

Correct answer: A

Rationale: The nurse should assess the client with a fractured femur and sharp chest pain first. Sharp chest pain in this client may indicate a pulmonary embolism, a life-threatening condition requiring immediate attention. The other options describe important patient conditions but do not pose an immediate threat to life like a potential pulmonary embolism does.

4. A nurse is providing teaching to a client who is scheduled for electromyography (EMG). Which of the following information should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D. During an electromyography (EMG) procedure, small needle electrodes are inserted into the muscles to identify muscle weakness and evaluate local nerve responses. This information is crucial for the client to know beforehand. Choice A is incorrect because radioisotopes are not used in EMG procedures. Choice B is incorrect because flushing is not a common occurrence during EMG. Choice C is incorrect because claustrophobia is more relevant to MRI or CT scans, not EMG procedures.

5. A nurse is caring for a client prescribed gabapentin. Which of the following should the nurse monitor?

Correct answer: B

Rationale: The correct answer is B: Renal function. Gabapentin is primarily eliminated by the kidneys, so monitoring renal function is essential to ensure the drug is being cleared effectively from the body. Monitoring liver function tests (choice A) is not a priority for gabapentin as it is not primarily metabolized by the liver. Blood glucose levels (choice C) are not directly impacted by gabapentin. Cardiac rhythm (choice D) monitoring is not typically necessary for clients on gabapentin unless they have pre-existing cardiac conditions that may be exacerbated by the medication.

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