RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN

Questions 65

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RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN Questions

Question 1 of 5

A nurse is caring for a client who has not voided for 8 hours following the removal of an indwelling urinary catheter. Which of the following actions should the nurse take first?

Correct Answer: D

Rationale: Performing a bladder scan is the first step to assess bladder retention before any further interventions.

Question 2 of 5

How is the effectiveness of a diuretic in a patient with heart failure evaluated?

Correct Answer: A

Rationale: The correct way to evaluate the effectiveness of a diuretic in a patient with heart failure is by checking daily weights and lung sounds for improvement. Daily weights help to assess fluid retention changes, while improvement in lung sounds indicates reduced pulmonary congestion. Assessing blood pressure and urine output (Choice B) is important but does not directly evaluate the effectiveness of the diuretic. Monitoring for weight loss and reduction in edema (Choice C) are valid indicators of diuretic effectiveness, but direct observation of daily weights and lung sounds is more specific. Measuring heart rate and lung sounds (Choice D) is relevant but does not directly assess the impact of the diuretic on fluid balance and pulmonary status.

Question 3 of 5

A nurse is caring for a client who had a total thyroidectomy and has a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?

Correct Answer: C

Rationale: The correct answer is C: Tingling of the extremities. Tingling is a common symptom of hypocalcemia, which is expected with low calcium levels after a thyroidectomy. Option A, shortened QT intervals, is associated with hypercalcemia rather than hypocalcemia. Option B, hypoactive deep tendon reflexes, is not typically related to hypocalcemia. Option D, constipation, is not a common finding associated with low calcium levels.

Question 4 of 5

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis?

Correct Answer: A

Rationale: Central cyanosis is best assessed by examining the oral mucosa, as it is a more reliable indicator compared to other areas like the conjunctivae, soles of the feet, and ear lobes. The oral mucosa reflects the oxygen saturation levels of the blood more accurately. Conjunctivae and ear lobes may show cyanosis, but they are not as reliable as the oral mucosa. The soles of the feet are not typically used to assess central cyanosis.

Question 5 of 5

When administering a subcutaneous injection of insulin to a client, what angle should the nurse use for the injection?

Correct Answer: C

Rationale: The correct angle for administering a subcutaneous injection, such as insulin, is 90 degrees. This angle allows for the medication to be delivered into the subcutaneous layer of tissue beneath the skin. A 45-degree angle is typically used for administering subcutaneous injections in infants or those with reduced adipose tissue, while a 60-degree angle is commonly used for intramuscular injections. A 30-degree angle is not a standard angle for subcutaneous injections.

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