PN ATI Capstone Proctored Comprehensive Assessment Form A

Questions 72

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PN ATI Capstone Proctored Comprehensive Assessment Form A Questions

Question 1 of 5

A client with chronic renal failure needs dietary instructions. Which of the following should the nurse provide?

Correct Answer: C

Rationale: The correct answer is to instruct the client to restrict protein intake. In chronic renal failure, the kidneys are unable to effectively filter waste products, so limiting protein helps reduce the buildup of waste in the body. Increasing calcium intake (Choice A) is not typically necessary unless there is a specific deficiency. Providing a diet high in potassium (Choice B) is contraindicated as potassium levels need to be monitored and controlled in renal failure. Increasing fluid intake (Choice D) may be necessary depending on the individual's condition, but restricting protein intake is a more critical dietary instruction for clients with chronic renal failure.

Question 2 of 5

A nurse is caring for a client who is 38 weeks pregnant and has a history of herpes simplex virus 2. Which question is most appropriate for the nurse to ask?

Correct Answer: C

Rationale: The most appropriate question for the nurse to ask is whether the client has any active herpes lesions. This is crucial because the presence of active lesions can necessitate a cesarean section to prevent transmission of the virus to the newborn. Asking about membrane rupture (choice A) is important but not directly related to the client's herpes simplex virus 2 status. Inquiring about the frequency of contractions (choice B) is relevant for assessing labor progression but does not address the immediate concern of herpes transmission. Asking about being positive for beta strep (choice D) is important for determining the need for prophylactic antibiotics during labor, but it is not directly related to the client's herpes simplex virus 2 status.

Question 3 of 5

A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?

Correct Answer: C

Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.

Question 4 of 5

A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?

Correct Answer: B

Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.

Question 5 of 5

A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?

Correct Answer: D

Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.

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