ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?
- A. Inflate the balloon with 10 mL of sterile water prior to insertion
- B. Cleanse the client’s labia and meatus using a front-to-back motion
- C. Ask the client to bear down while inserting the catheter
- D. Inflate the catheter balloon after urine begins to flow
Correct answer: D
Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.
2. A nurse is planning to administer several medications to a client through an NG tube. Which actions should the nurse take?
- A. Dissolve crushed tablet medications in tap water
- B. Use 30-40 mL of sterile water for each medication
- C. Dissolve crushed tablet medications in sterile water
- D. Administer medications without dissolving
Correct answer: C
Rationale: The correct action for the nurse to take when administering medications through an NG tube is to dissolve crushed tablet medications in 15-30 mL of sterile water. This ensures proper delivery through the NG tube and reduces the risk of clogging. Choice A is incorrect because tap water may contain impurities that can cause complications. Choice B suggests using a higher volume of sterile water than necessary, which may lead to dilution of the medications. Choice D is incorrect as medications should be dissolved to prevent blockages in the NG tube.
3. When resolving a conflict, which statement made by the charge nurse is an example of smoothing?
- A. You have been a nurse a long time, so I’m sure you’re capable of the tasks.
- B. If you prefer, I can take over your assignment.
- C. We can switch your assignment with someone else.
- D. Let’s discuss your concerns in a private setting.
Correct answer: A
Rationale: The correct answer is A because it exemplifies smoothing, a conflict resolution strategy where the charge nurse reassures the staff nurse of their capabilities. Choice B offers to take over the assignment, which is more of a compromising strategy. Choice C suggests switching assignments, which aligns with compromising rather than smoothing. Choice D proposes a discussion in a private setting, indicating a collaborating approach rather than smoothing.
4. A nurse is reviewing laboratory results for a client receiving chemotherapy. Which result should the nurse report to the provider?
- A. WBC 3,000/mm³
- B. Hemoglobin 12 g/dL
- C. Platelet count 250,000/mm³
- D. Serum sodium 140 mEq/L
Correct answer: A
Rationale: The correct answer is A: WBC 3,000/mm³. A WBC count of 3,000/mm³ indicates neutropenia, which is a condition characterized by a low level of white blood cells, specifically neutrophils. Neutropenia increases the risk of infection and requires immediate medical attention, especially in clients undergoing chemotherapy. Reporting this result to the provider promptly is crucial for further evaluation and intervention. Choices B, C, and D are within normal ranges and do not pose an immediate risk to the client's health. Hemoglobin of 12 g/dL, platelet count of 250,000/mm³, and serum sodium of 140 mEq/L are all normal values and would not typically require immediate reporting unless there are specific concerns related to the individual client's condition.
5. A nurse is reviewing a prescription for doxazosin with a client. Which instruction should the nurse include?
- A. Decrease caloric intake to reduce weight gain
- B. Increase dietary fiber to prevent constipation
- C. Rise slowly when sitting up
- D. Take this medication each morning
Correct answer: C
Rationale: The correct answer is C: 'Rise slowly when sitting up.' Doxazosin can cause orthostatic hypotension, a sudden drop in blood pressure when standing up, leading to dizziness or fainting. Instructing the client to rise slowly helps prevent this adverse effect. Choices A, B, and D are incorrect. A decrease in caloric intake to reduce weight gain, an increase in dietary fiber to prevent constipation, and taking the medication each morning are not specific instructions related to managing the side effects of doxazosin.
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