ATI LPN
PN ATI Capstone Maternal Newborn
1. A newborn demonstrates respiratory distress, and routine suctioning with the bulb syringe is unsuccessful. What is the next nursing intervention?
- A. Initiate chest compressions
- B. Administer oxygen
- C. Suction with a mechanical device
- D. Notify the healthcare provider
Correct answer: C
Rationale: When routine suctioning with a bulb syringe is unsuccessful in a newborn demonstrating respiratory distress, the next appropriate nursing intervention is to suction with a mechanical device. This method ensures effective removal of any airway obstruction. Initiating chest compressions (Choice A) is not indicated in this scenario as the primary concern is airway clearance. Administering oxygen (Choice B) may be necessary, but addressing the airway obstruction should take precedence. Notifying the healthcare provider (Choice D) can be considered after attempting mechanical suction if the newborn's condition does not improve.
2. A nurse is caring for a client with a new prescription for furosemide. Which of the following should the nurse monitor?
- A. Serum potassium levels
- B. Liver function
- C. Blood glucose levels
- D. Calcium levels
Correct answer: A
Rationale: Corrected Rationale: When a client is prescribed furosemide, the nurse should monitor serum potassium levels. Furosemide is a loop diuretic that can lead to potassium loss, potentially causing hypokalemia. Monitoring serum potassium levels is crucial to prevent complications such as cardiac dysrhythmias. Choices B, C, and D are incorrect because furosemide primarily affects potassium excretion rather than liver function, blood glucose levels, or calcium levels.
3. A client prescribed allopurinol for gout is being taught by a nurse. Which of the following should be included in the teaching?
- A. Take the medication with meals.
- B. Drink at least 2 liters of water per day.
- C. Avoid foods high in purines.
- D. Increase your dietary intake of calcium.
Correct answer: B
Rationale: The correct answer is B: 'Drink at least 2 liters of water per day.' Clients taking allopurinol should be instructed to drink plenty of water to prevent kidney stones, a potential side effect of the medication. Option A is incorrect because allopurinol is usually taken without regard to meals. Option C is not directly related to the teaching about allopurinol, as it pertains more to dietary management of gout. Option D is also unrelated to allopurinol use for gout.
4. A nurse is caring for a client who had a stroke and is showing signs of dysphagia. Which of the following findings should the nurse recognize as an indication of this condition?
- A. Abnormal movements of the mouth
- B. Inability to stand without assistance
- C. Paralysis of the right arm
- D. Loss of appetite
Correct answer: A
Rationale: Abnormal movements of the mouth are a common indication of dysphagia, a condition that impairs swallowing function. In clients who have had a stroke, dysphagia can increase the risk of aspiration, leading to serious complications. Inability to stand without assistance (Choice B) is more indicative of motor deficits following a stroke rather than dysphagia. Paralysis of the right arm (Choice C) is a manifestation of hemiplegia, which is common in stroke but not directly related to dysphagia. Loss of appetite (Choice D) may occur in individuals with dysphagia but is not a direct indicator of the condition itself.
5. A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the nurse identify as examples of cultural variables?
- A. Eye contact
- B. Personal space
- C. Touch
- D. All of the above
Correct answer: D
Rationale: In a cultural assessment, it is essential to consider various cultural variables that can impact communication and interactions. Eye contact, personal space, and touch are examples of cultural variables that can vary among different cultural groups. These variables influence how individuals perceive and engage in communication. Understanding and respecting these differences are crucial for effective and culturally sensitive care. Therefore, the correct answer is 'All of the above.' Choices A, B, and C are incorrect because each of them represents a cultural variable that should be considered during a cultural assessment.
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