PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

Correct Answer: B

Rationale: The correct answer is to assess blood pressure first. Enalapril is an ACE inhibitor commonly used to manage hypertension. It is crucial to evaluate the patient's blood pressure before administering enalapril to ensure it is within safe limits. Assessing other parameters like heart rate, serum creatinine, and potassium levels is also important but assessing blood pressure takes precedence due to the medication's mechanism of action and potential effects on blood pressure regulation.

Correct Answer: C

Rationale: The correct answer is C: Client's vaccination history. Before administering a pneumococcal vaccine, the nurse should verify the client's vaccination history to ensure they are due for the vaccine. Verifying the vaccination history helps prevent unnecessary vaccinations and ensures that the client receives the appropriate immunization at the right time. Choices A, B, and D are not directly related to the administration of the pneumococcal vaccine. Checking for allergies to eggs may be important for other vaccines, but it is not specifically relevant to pneumococcal vaccination. The client's current medications and blood pressure are important for general health assessment but are not directly related to verifying the need for a pneumococcal vaccine.

Correct Answer: B

Rationale: The correct answer is B: 'It can cause bradycardia.' Digoxin can cause bradycardia as one of its side effects. Clients should be educated about this potential effect and instructed to monitor their heart rate before taking the medication. Choice A is incorrect because digoxin is more likely to cause arrhythmias than low blood pressure. Choice C is incorrect as calcium supplements can interfere with the absorption of digoxin. Choice D is incorrect as digoxin has various side effects, and clients should be aware of them.

Correct Answer: D

Rationale: Hourly rounding by the nurse is the most effective intervention to reduce the risk of falls in older adult clients with delirium. This intervention ensures that the nurse regularly checks on the client, assesses their needs, and assists them with any activities, thereby minimizing the chances of falls. Using a night-light (choice A) may help improve visibility but does not provide continuous assistance and monitoring. Demonstrating how to use the call light (choice B) is important but may not prevent falls directly. Placing the bedside table in close proximity (choice C) is helpful for convenience but does not address the continuous monitoring and assistance needed to prevent falls in this case.

Correct Answer: B

Rationale: The correct answer is B: Fatigue. Fatigue, along with symptoms like shakiness and irritability, are common signs of hypoglycemia. Increased thirst (Choice A) is more indicative of hyperglycemia. Weight gain (Choice C) is not typically associated with hypoglycemia. Elevated blood pressure (Choice D) is not a common sign of hypoglycemia.