ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?
- A. Urinary output of 40 mL/hr
- B. Respiratory rate of 10 breaths per minute
- C. Absent deep tendon reflexes
- D. Blood pressure of 150/90 mm Hg
Correct answer: B
Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention. Urinary output of 40 mL/hr (Choice A) is within the normal range for a client receiving magnesium sulfate. Absent deep tendon reflexes (Choice C) are an expected finding due to the medication's effect on neuromuscular excitability. A blood pressure of 150/90 mm Hg (Choice D) is slightly elevated but not a priority concern compared to severe respiratory depression.
2. What is an example of a culturally sensitive response from a healthcare provider when a patient mentions feeling uncomfortable with a treatment plan?
- A. Asking why they feel this way
- B. Explaining that the treatment is standard
- C. Inviting the patient to share concerns
- D. Offering alternative treatments
Correct answer: C
Rationale: Inviting the patient to share concerns is an example of a culturally sensitive response as it acknowledges the patient's feelings and provides a safe space for them to express their discomfort. This approach shows respect for the patient's cultural beliefs and values by valuing their perspective. Choice A, asking why they feel this way, can be perceived as confrontational and may not encourage open communication. Choice B, explaining that the treatment is standard, dismisses the patient's feelings and does not address their discomfort. Choice D, offering alternative treatments, may be premature without fully understanding the patient's concerns first.
3. A client has a new prescription for oxcarbazepine. Which of the following should the nurse monitor?
- A. Liver function
- B. Serum sodium levels
- C. Blood glucose
- D. Heart rate
Correct answer: B
Rationale: The correct answer is B: Serum sodium levels. Oxcarbazepine can lead to hyponatremia, making it crucial to monitor serum sodium levels. Monitoring liver function (choice A) is not typically associated with oxcarbazepine use. Blood glucose (choice C) monitoring is more relevant in medications affecting blood sugar levels. Heart rate (choice D) is not directly impacted by oxcarbazepine.
4. A client with hepatic encephalopathy is being cared for by a nurse. Which food selection indicates the client understands dietary teaching?
- A. A sandwich and milkshake
- B. Rice with black beans
- C. Cottage cheese and tuna lettuce
- D. Three-egg omelet with low-sodium ham
Correct answer: B
Rationale: For clients with hepatic encephalopathy, foods high in protein like cottage cheese and tuna should be avoided. Plant-based protein sources like beans are recommended due to their lower ammonia production during digestion. Therefore, the correct choice is B. Choices A, C, and D are incorrect as they include high-protein or high-sodium foods that can worsen the condition of hepatic encephalopathy.
5. A patient is scheduled for cataract surgery but decides to cancel, stating 'I see just fine.' Which of the following responses should the nurse make?
- A. That’s not a good idea; the surgery is necessary
- B. Share with me more about the thoughts that are concerning you
- C. You should trust your doctor’s advice
- D. You can always reschedule the surgery later
Correct answer: B
Rationale: The correct response is to encourage the patient to share more about their concerns. This approach helps the nurse understand the patient's perspective and allows for a supportive discussion. Choice A is dismissive and does not address the patient's feelings. Choice C may undermine the patient's autonomy and decision-making. Choice D suggests delaying without addressing the patient's current decision.
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