a nurse is preparing to administer a dose of enalapril which of the following should the nurse assess first
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. A nurse is preparing to administer a dose of enalapril. Which of the following should the nurse assess first?

Correct answer: B

Rationale: The correct answer is to assess blood pressure first. Enalapril is an ACE inhibitor commonly used to manage hypertension. It is crucial to evaluate the patient's blood pressure before administering enalapril to ensure it is within safe limits. Assessing other parameters like heart rate, serum creatinine, and potassium levels is also important but assessing blood pressure takes precedence due to the medication's mechanism of action and potential effects on blood pressure regulation.

2. A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?

Correct answer: C

Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.

3. A nurse is caring for an older adult who has a non-palpable skin lesion that is less than 0.5 cm in diameter. Which term should the nurse use to document this finding?

Correct answer: B

Rationale: The correct answer is B: Macule. A macule is a non-palpable skin lesion smaller than 1 cm in diameter. In this case, the skin lesion described is less than 0.5 cm, making it consistent with a macule. Vesicle (choice A) is a small blister filled with clear fluid, papule (choice C) is a solid, raised skin lesion less than 0.5 cm in diameter, and nodule (choice D) is a palpable, solid lesion larger than 0.5 cm in diameter. Therefore, choices A, C, and D describe skin lesions that do not match the characteristics of the lesion presented in the question.

4. Four clients present to the emergency department. The nurse should plan to see which of the following clients first?

Correct answer: D

Rationale: The correct answer is D. The client with slurred speech and a headache may be experiencing a stroke, which is a medical emergency that requires immediate attention to prevent irreversible brain damage. While each client requires prompt assessment and care, the priority is to address potentially life-threatening conditions first. Choices A, B, and C, although important, do not present with symptoms as critical as those of a possible stroke, which necessitates urgent intervention.

5. A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?

Correct answer: A

Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.

Similar Questions

A postpartum client's fundus is firm, 3 cm above the umbilicus, and displaced to the right. Which of the following interventions should the nurse take?
A nurse is teaching a client with mild persistent asthma who has been prescribed montelukast. Which statement by the nurse is appropriate?
A nurse manager is teaching a group of employees about QSEN. What statement by an employee should the nurse manager identify as quality improvement?
A nurse is preparing to administer lactated Ringer's (LR) 1,000 mL IV to infuse over 8 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate via IV infusion. Which of the following findings indicates magnesium toxicity?

Access More Features

ATI LPN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

ATI LPN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • All ATI courses Coverage
  • 30 days access

Other Courses