PN ATI Capstone Proctored Comprehensive Assessment Form A

Correct Answer: D

Rationale: The correct answer is to restrict protein intake for a client with chronic renal failure. In renal failure, the kidneys are unable to effectively filter waste products. Excessive protein intake can lead to the accumulation of waste products, increasing the workload on the kidneys. Therefore, restricting protein intake is essential to prevent further kidney damage. Choices A, B, and C are incorrect. Increasing calcium intake is not specifically indicated for chronic renal failure. Increasing potassium intake can be dangerous in renal failure as impaired kidneys may not be able to excrete excess potassium. Increasing protein intake is contraindicated in chronic renal failure as it can worsen kidney function and increase the accumulation of waste products.

Correct Answer: B

Rationale: The correct answer is B. A urine output of 20 mL/hour is a sign of magnesium toxicity because decreased urine output can lead to accumulation of magnesium. Choices A, C, and D are not indicators of magnesium toxicity. Elevated blood glucose, high systolic blood pressure, and normal BUN levels do not specifically point towards magnesium toxicity.

Correct Answer: C

Rationale: The correct action for a nurse when administering enoxaparin for DVT prevention is to inject the medication into the lateral abdominal wall. This is the recommended site for enoxaparin administration. Expelling the air bubble is unnecessary and may lead to a dosage error. Massaging the injection site is not recommended as it can cause bruising. Administering an NSAID for injection site discomfort is not necessary as discomfort should be minimal and transient.

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.

Correct Answer: D

Rationale: The correct answer is D. Increased urinary output greater than fluid intake can indicate diabetes insipidus, a common complication after pituitary surgery. Diabetes insipidus is characterized by the excretion of a large volume of dilute urine, leading to dehydration and electrolyte imbalances. This finding requires immediate assessment and intervention. Choice A, a Glasgow scale score of 15, indicates normal neurological functioning. Choice B, blood drainage on dressing measuring 3 cm, may require monitoring but is not a priority over the potential complication of diabetes insipidus. Choice C, a report of dry mouth, is a common complaint postoperatively and can be managed with oral care measures.