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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 warfarin. Which of the following actions should the healthcare professional take?
- A. Verify INR levels
- B. Administer with food
- C. Monitor blood glucose levels
- D. Assess liver function
Correct answer: A
Rationale: Corrected Rationale: When administering warfarin, it is crucial to verify the patient's INR levels. INR monitoring is essential to ensure that the patient is receiving the correct dose of warfarin for their condition and to minimize the risk of bleeding. Choices B, C, and D are incorrect because administering warfarin with food, monitoring blood glucose levels, and assessing liver function are not directly related to the safe administration and monitoring of warfarin therapy.
2. A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. The client reports heavy bleeding and passing large clots. What is the priority action for the nurse to take?
- A. Administer oxytocin IV
- B. Perform fundal massage
- C. Check vital signs
- D. Encourage the client to void
Correct answer: B
Rationale: Performing fundal massage is the priority action to take in this situation. Fundal massage helps stimulate uterine contractions, which can reduce postpartum bleeding. Uterine atony, the most common cause of early postpartum hemorrhage, can be addressed effectively through fundal massage. Administering oxytocin IV, although important, should come after initiating fundal massage. Checking vital signs is also crucial but not the immediate priority. Encouraging the client to void does not directly address the heavy bleeding and passing of large clots; hence, it is not the priority action.
3. When teaching about safety risks for adolescents, what should be included?
- A. Adolescents are more likely to follow rules
- B. Peer influence to participate in high-risk behaviors can lead to injury
- C. Most injuries occur during sports activities
- D. Adolescents are aware of the dangers of substance use
Correct answer: B
Rationale: When educating about safety risks for adolescents, it is crucial to address the impact of peer influence on engaging in high-risk behaviors, which can result in injuries. Choice A is incorrect because adolescents are known to sometimes take risks and not always follow rules. Choice C is incorrect as injuries among adolescents can also happen outside of sports activities. Choice D is incorrect as adolescents may not always be fully aware of the dangers of substance use.
4. A nurse is caring for a client prescribed prednisone. Which of the following should the nurse monitor?
- A. Blood glucose levels
- B. Serum potassium levels
- C. Liver function tests
- D. Heart rate
Correct answer: A
Rationale: Corrected Rationale: Prednisone is known to cause hyperglycemia by increasing blood glucose levels. Monitoring blood glucose levels is crucial to detect and manage any potential hyperglycemic effects of prednisone. While prednisone can also affect serum potassium levels and liver function, the priority monitoring parameter in this case is blood glucose levels. Monitoring heart rate is not directly associated with prednisone administration, making it a less relevant parameter to monitor in this scenario.
5. When a nurse is interviewing a client who is requesting oral contraceptives, which finding in the client’s history is a contraindication to combined oral contraceptives?
- A. Thyroid disease
- B. Allergy to penicillin
- C. Impaired liver function
- D. Abnormal blood glucose levels
Correct answer: C
Rationale: The correct answer is C: Impaired liver function. Impaired liver function is a contraindication to the use of oral contraceptives because they are metabolized in the liver. Choices A, B, and D are incorrect. Thyroid disease, allergy to penicillin, and abnormal blood glucose levels are not contraindications to combined oral contraceptives.
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