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PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. When teaching a client about the use of trazodone, what should be included?
- A. It can cause sedation
- B. It is a stimulant
- C. It has no side effects
- D. It should be taken with food
Correct answer: A
Rationale: The correct answer is A. Trazodone can cause sedation, so clients should be cautioned about activities requiring alertness, like driving. Choice B is incorrect because trazodone is not a stimulant; it is actually a sedating antidepressant. Choice C is incorrect as all medications have potential side effects. Choice D is not specifically indicated for trazodone; the client should follow the prescribing healthcare provider's instructions regarding food intake.
2. A nurse is teaching a group of clients about the risk factors for osteoporosis. Which of the following should the nurse include as a risk factor for osteoporosis?
- A. Early menopause
- B. History of falls
- C. African American race
- D. Obesity
Correct answer: A
Rationale: The correct answer is A: Early menopause. A client who goes into early menopause, from natural or surgical causes, is at greater risk for developing osteoporosis due to the rapid drop in estrogen levels. Choice B, history of falls, is not a direct risk factor for osteoporosis but can lead to fractures in individuals with osteoporosis. Choice C, African American race, is actually associated with a lower risk of osteoporosis compared to Caucasian or Asian descent. Choice D, obesity, is generally considered a protective factor against osteoporosis due to the increased mechanical loading on bones.
3. A nurse is caring for a client who has a deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate frequently.
- B. Apply warm, moist compresses to the affected leg.
- C. Massage the affected leg.
- D. Place the client in a supine position.
Correct answer: B
Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply warm, moist compresses to the affected leg. This helps alleviate pain and improve circulation in the affected area, aiding in the treatment of DVT. Encouraging the client to ambulate frequently (Choice A) is contraindicated as it can dislodge the clot and lead to complications. Massaging the affected leg (Choice C) is also contraindicated as it can dislodge the clot and potentially cause an embolism. Placing the client in a supine position (Choice D) is not specifically indicated for DVT treatment; elevation of the affected leg is preferred over placing the client completely supine.
4. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?
- A. Bladder distention
- B. Frequent urination
- C. Dark urine
- D. Increased thirst
Correct answer: A
Rationale: Bladder distention is the correct sign of catheter occlusion. When a catheter is occluded, the urine cannot drain properly, leading to the buildup of urine in the bladder and subsequent distention. Frequent urination, dark urine, and increased thirst are not typical signs of catheter occlusion. Frequent urination can be a sign of conditions like urinary tract infection, dark urine may indicate dehydration or other issues, and increased thirst can be related to various factors like diabetes or medication side effects.
5. A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the following clients should the nurse identify as the priority?
- A. A client who has massive head trauma
- B. A client who has full-thickness burns to the face and trunk
- C. A client with indications of hypovolemic shock
- D. A client with an open fracture of the lower extremity
Correct answer: C
Rationale: In a mass casualty situation, the nurse should prioritize the client with indications of hypovolemic shock. Hypovolemic shock is an immediate life-threatening condition resulting from severe blood loss, which can lead to organ failure and death. Prompt identification and treatment of hypovolemic shock are crucial to prevent further deterioration. While clients with massive head trauma, full-thickness burns, and open fractures require urgent care, hypovolemic shock takes precedence due to its rapid progression to a critical state.
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