a nurse is assessing a client who has severe dehydration which finding indicates effective treatment
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Nursing Elites

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PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?

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.

2. A healthcare professional is preparing to administer a dose of potassium chloride. Which of the following should the professional do?

Correct answer: B

Rationale: Correct Answer: Dilute the medication. Potassium chloride should always be diluted before administration to avoid irritation and complications. Choice A is incorrect because administering it as a bolus can lead to adverse effects. Choice C is incorrect as giving it rapidly can be dangerous. Choice D is incorrect as monitoring the respiratory rate is not directly related to administering potassium chloride.

3. A community health nurse is teaching a group of clients about first aid for wounds. Which client statement indicates understanding?

Correct answer: B

Rationale: The correct answer is B. Applying clean dressings over blood-saturated ones and holding pressure helps to control bleeding and prevent tissue disruption. Removing blood-saturated dressings can cause further damage by disrupting the forming clot. Elevating the wound above heart level is beneficial to reduce swelling, but it is not the best immediate action for a blood-saturated dressing. Leaving the wound open to air can increase the risk of infection and slow down the healing process.

4. A nurse is planning to discharge a client who has quadriplegia to his home. The nurse suggests that the family might need respite care services. When a family member asks how respite care can help, which response should the nurse provide?

Correct answer: D

Rationale: The correct answer is D. Respite care is designed to give primary caregivers temporary relief from the responsibilities of care, allowing them to take a break. Choice A is incorrect because respite care is not primarily focused on providing medical support to the client. Choice B is incorrect as respite care does not specifically assist with financial planning for the client's needs. Choice C is incorrect as respite care does not provide long-term housing, but rather short-term relief for caregivers.

5. A nurse is observing bonding between the client and her newborn. Which of the following actions by the client requires the nurse to intervene?

Correct answer: D

Rationale: The correct answer is D because viewing the newborn’s actions as uncooperative indicates a negative interaction with the newborn and suggests impaired bonding, which requires intervention. Choices A, B, and C are not indicative of impaired bonding. Holding the newborn in an en face position is a positive way to bond with the baby. Asking the father to change the diaper shows involvement of both parents in caring for the newborn, which is beneficial for bonding. Requesting the nurse to take the newborn to the nursery so the mother can rest is a normal request and does not necessarily indicate impaired bonding.

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