a nurse is assessing a client who has a long arm cast which of the following findings indicates a moderate complication when assessing for acute compa
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A healthcare provider is assessing a client who has a long arm cast. Which of the following findings indicates a moderate complication when assessing for acute compartment syndrome?

Correct answer: D

Rationale: Edema is a common sign of acute compartment syndrome, which is a medical emergency caused by increased pressure within a muscle compartment, requiring immediate intervention. Shortness of breath (Choice A) is more indicative of a respiratory issue rather than acute compartment syndrome. Petechiae (Choice B) are pinpoint, round spots that appear on the skin due to bleeding under the skin and are not typically associated with acute compartment syndrome. Change in mental status (Choice C) is more suggestive of neurological issues rather than acute compartment syndrome.

2. A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which of the following client information should the nurse identify as a contributing factor?

Correct answer: A

Rationale: The correct answer is A. Recurring bowel inflammation can decrease gastrointestinal motility, affecting the absorption of oral medications. This can lead to decreased effectiveness of the arthritis medication. Choice B is incorrect because increasing exercise would not typically impact the absorption of arthritis medication. Choice C is incorrect as herbal supplements may not directly affect the absorption of conventional arthritis medication. Choice D is also incorrect as stress, while it can impact overall health, is less likely to directly affect the effectiveness of arthritis medication compared to gastrointestinal issues.

3. A client had a pituitary tumor removed. Which of the following findings requires further assessment?

Correct answer: D

Rationale: The correct answer is D. Increased urinary output greater than fluid intake can indicate diabetes insipidus, a common complication after pituitary surgery. Diabetes insipidus is characterized by the excretion of a large volume of dilute urine, leading to dehydration and electrolyte imbalances. This finding requires immediate assessment and intervention. Choice A, a Glasgow scale score of 15, indicates normal neurological functioning. Choice B, blood drainage on dressing measuring 3 cm, may require monitoring but is not a priority over the potential complication of diabetes insipidus. Choice C, a report of dry mouth, is a common complaint postoperatively and can be managed with oral care measures.

4. A healthcare professional is assessing a client for potential complications after surgery. Which of the following should the healthcare professional monitor for?

Correct answer: A

Rationale: Corrected Rationale: Decreased urine output can indicate renal complications or dehydration, which are common post-surgical complications. Monitoring urine output is crucial for detecting early signs of kidney dysfunction or fluid imbalances. Increased appetite, improved mobility, and normal temperature are not typical signs of immediate post-surgical complications and would not be the priority for monitoring in this case.

5. A client is receiving vancomycin. Which of the following should the nurse monitor?

Correct answer: B

Rationale: The correct answer is B: Serum creatinine. Vancomycin is known to be nephrotoxic, meaning it can cause kidney damage. Monitoring serum creatinine levels is essential to assess kidney function and detect any signs of nephrotoxicity. Blood glucose levels (choice A) are not directly affected by vancomycin. INR levels (choice C) are typically monitored for clients on anticoagulants, not vancomycin. Liver function tests (choice D) are not primarily affected by vancomycin use; kidney function is of greater concern.

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