a nurse is teaching a client who is at 24 weeks of gestation about the signs of preterm labor which of the following should the nurse include
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PN ATI Capstone Proctored Comprehensive Assessment Form B

1. A client who is at 24 weeks of gestation is being taught about the signs of preterm labor. Which of the following should the nurse include?

Correct answer: B

Rationale: The correct answer is B: Regular contractions. Regular contractions before 37 weeks of gestation are a significant sign of preterm labor. It is essential for clients to be aware of this symptom and report it promptly to their healthcare provider. Choices A, C, and D are incorrect because sudden weight loss, shortness of breath, and vaginal spotting are not typical signs of preterm labor. Teaching clients about the specific signs of preterm labor can help in early detection and intervention, ultimately improving outcomes for both the client and the baby.

2. A client with a new diagnosis of hypertension is being taught about lifestyle modifications by a nurse. What dietary change should the nurse recommend?

Correct answer: B

Rationale: The correct answer is B: Limit alcohol consumption. When managing hypertension, it is crucial to reduce alcohol intake as it can raise blood pressure. High alcohol consumption can also interfere with the effectiveness of antihypertensive medications. Choices A, C, and D are incorrect. Increasing sodium intake (Choice A) is not recommended for hypertension as it can lead to fluid retention and elevated blood pressure. Eating a high-protein diet (Choice C) or following a high-fat diet (Choice D) are also not ideal for managing hypertension, as they can have negative impacts on cardiovascular health.

3. A client is experiencing suicidal thoughts and states, 'Why not end my misery?' What is the best response by the nurse?

Correct answer: B

Rationale: The correct answer is B: 'Do you have a plan to end your life?' When a client expresses suicidal thoughts, it is crucial to assess the immediate risk. Inquiring about a specific plan can help determine the seriousness of the situation. Choice A is less direct and may not provide a clear indication of the immediate risk. Choice C focuses on the interpretation of 'misery' rather than assessing the risk of suicide. Choice D offers support but does not address the critical assessment of the client's immediate safety.

4. A nurse is providing teaching for a child who is prescribed ferrous sulfate. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Take with a glass of orange juice.' Ferrous sulfate should be taken with orange juice (vitamin C) to enhance the absorption of iron. Taking it with milk (choice A) is not recommended as calcium can interfere with iron absorption. Taking it at bedtime (choice C) or with meals (choice D) may lead to decreased absorption due to interactions with other food or medications.

5. A healthcare provider is preparing to administer a dose of levothyroxine. Which of the following should the healthcare provider do?

Correct answer: B

Rationale: The correct answer is to assess the patient's heart rate. Levothyroxine is a thyroid hormone replacement medication that can increase metabolism. One of the potential side effects of levothyroxine is tachycardia (rapid heart rate). Therefore, it is essential for the healthcare provider to assess the patient's heart rate before administering the medication to monitor for any signs of tachycardia. Giving levothyroxine with food may affect its absorption, so it is typically recommended to administer it on an empty stomach. Administering it in the evening is not necessary unless specifically prescribed by the healthcare provider, and giving it with calcium supplements can interfere with the absorption of levothyroxine.

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