a nurse is planning care for an adolescent client with chronic renal failure which action should the nurse include
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PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is planning care for an adolescent client with chronic renal failure. Which action should the nurse include?

Correct answer: D

Rationale: In chronic renal failure, it is essential to restrict protein intake to the Recommended Dietary Allowance (RDA) to reduce the accumulation of waste products that the kidneys can no longer effectively eliminate. Choices A, B, and C are incorrect because in chronic renal failure, high calcium, high potassium, and increased fluid intake can further strain the kidneys and worsen the condition.

2. A nurse in the emergency department is prioritizing care for four clients. Which of the following clients should the nurse see first?

Correct answer: D

Rationale: The client with slurred speech, disorientation, and a headache may be experiencing a stroke, a life-threatening condition that requires immediate attention. Identifying and managing a stroke promptly can reduce the risk of long-term disability or complications. The other options, although important, do not present immediate life-threatening conditions that require urgent intervention. A dislocated shoulder, severe joint pain in sickle cell disease, confusion with fever and foul-smelling urine, while concerning, can be addressed after attending to the client with potential stroke symptoms.

3. A home health nurse is carefully planning care for a client with Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?

Correct answer: A

Rationale: Placing a daily calendar in the kitchen is essential for clients with Alzheimer's disease as it helps in orienting them to time and day, providing structure, and minimizing confusion in their daily routine. This action supports cognitive function and independence. Choice B is incorrect as it does not directly address cognitive orientation. Choice C is not a priority in the care plan and may not significantly impact the client's daily functioning. Choice D, creating variation in the daily routine, can actually increase confusion and anxiety in clients with Alzheimer's disease who thrive on predictability and structure.

4. A nurse is reviewing discharge instructions with the parents of a newborn. Which of the following statements indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D. Leaving the baby's diaper off to prevent diaper rash is not recommended because it increases the risk of infection. Proper diaper hygiene and frequent diaper changes are more effective in preventing diaper rash. Choices A, B, and C are correct as placing the baby on its back to sleep, giving the baby a pacifier at bedtime, and keeping the baby's crib free of blankets and toys are appropriate measures to ensure the newborn's safety and reduce the risk of Sudden Infant Death Syndrome (SIDS).

5. A client is being treated with thiazide diuretics. What should the nurse monitor regularly?

Correct answer: B

Rationale: Thiazide diuretics are known to cause hypokalemia by increasing potassium excretion in the urine. Therefore, the nurse should monitor the client for low potassium levels. Hyperkalemia (Choice A) is not typically associated with thiazide diuretics. Hyponatremia (Choice C) is more commonly linked with thiazide diuretics due to increased sodium excretion. Hypoglycemia (Choice D) is not a usual concern when a client is receiving thiazide diuretics.

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