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PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A healthcare professional is preparing to administer a dose of potassium chloride. Which of the following actions should the healthcare professional take?
- A. Administer rapidly
- B. Dilute the medication before administration
- C. Give it as a bolus
- D. Administer it intramuscularly
Correct answer: B
Rationale: The correct action when administering potassium chloride is to dilute the medication before administration. Potassium chloride is a highly concentrated solution that can cause irritation and potential complications if not properly diluted. Administering it rapidly (choice A) can lead to adverse effects. Giving it as a bolus (choice C) or administering it intramuscularly (choice D) are inappropriate routes for potassium chloride administration and can result in harm to the patient.
2. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate. Which of the following is an indication of magnesium toxicity?
- A. Blood glucose of 160 mg/dL
- B. Urine output of 20 mL/hour
- C. Systolic BP of 140 mm Hg
- D. Respiratory rate of 20/min
Correct answer: B
Rationale: The correct answer is B: Urine output of 20 mL/hour. Urine output below 30 mL/hour is a sign of magnesium toxicity due to the risk of accumulation in the body. Choices A, C, and D are not indicative of magnesium toxicity. Elevated blood glucose, systolic blood pressure, and normal respiratory rate are not specific signs of magnesium toxicity.
3. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?
- A. Diaphoresis
- B. Polyuria
- C. Abdominal pain
- D. Thirst
Correct answer: A
Rationale: The correct answer is A: Diaphoresis. Diaphoresis (sweating) is a classic symptom of hypoglycemia, along with shakiness, confusion, and irritability. These signs help indicate low blood sugar levels. Choices B, C, and D are incorrect. Polyuria (excessive urination), abdominal pain, and thirst are not typical symptoms associated with hypoglycemia. It is crucial for clients with type 1 diabetes mellitus to recognize the early signs of hypoglycemia to take prompt corrective action.
4. A charge nurse is teaching a new nurse how to clean surfaces contaminated with blood. Which agent should the charge nurse include in the teaching?
- A. Hydrogen peroxide
- B. Chlorhexidine
- C. Isopropyl alcohol
- D. Chlorine bleach
Correct answer: D
Rationale: Chlorine bleach is the most appropriate agent for disinfecting surfaces contaminated with blood. It is effective in killing a wide range of pathogens, including viruses. Hydrogen peroxide (Choice A) is not as effective as chlorine bleach for bloodborne pathogen disinfection. Chlorhexidine (Choice B) and isopropyl alcohol (Choice C) are more commonly used for skin antisepsis rather than surface disinfection, making them less suitable options in this scenario.
5. During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
- A. An irregularly shaped, nontender lump palpable in the right breast
- B. Tenderness present during menstruation
- C. Bilateral, symmetrical lumps that move with palpation
- D. The client reports breast tenderness before menstruation
Correct answer: A
Rationale: An irregularly shaped, nontender lump is a concerning finding as it may indicate breast cancer. The nurse should report this finding to the provider for further investigation. Choices B, C, and D are less concerning findings. Tenderness during menstruation is a common finding due to hormonal changes. Bilateral, symmetrical lumps that move with palpation are often benign findings like fibrocystic changes. Breast tenderness before menstruation is also a common occurrence related to hormonal fluctuations.
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