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PN ATI Capstone Fundamentals Quiz
1. A nurse is performing a focused assessment for a client who has dysrhythmias. What indicates ineffective cardiac contractions?
- A. Increased blood pressure
- B. Pulse deficit
- C. Normal heart rate
- D. Elevated oxygen saturation
Correct answer: B
Rationale: The correct answer is B: Pulse deficit. A pulse deficit is a significant finding in clients with dysrhythmias, indicating ineffective cardiac contractions. Pulse deficit occurs when there is a difference between the apical and radial pulses, suggesting that not all heart contractions are strong enough to produce a pulse that can be felt peripherally. Increased blood pressure (choice A) may occur due to various factors and is not a direct indicator of ineffective cardiac contractions. Similarly, a normal heart rate (choice C) and elevated oxygen saturation (choice D) do not specifically point towards ineffective cardiac contractions; they can be present in individuals with dysrhythmias but do not directly indicate ineffective cardiac contractions.
2. A nurse in an acute care facility is caring for a client who is postop following abdominal surgery. Which of the following behaviors should the nurse identify as increasing the client's risk for constipation?
- A. Regular fluid intake
- B. Urge suppression
- C. Increased physical activity
- D. Adequate dietary fiber
Correct answer: B
Rationale: Urge suppression can lead to constipation by delaying bowel movements and causing fecal impaction, especially in postoperative patients. Regular fluid intake (choice A) is important to prevent constipation by maintaining hydration and aiding in bowel movements. Increased physical activity (choice C) helps stimulate bowel function and prevent constipation. Adequate dietary fiber (choice D) is essential for promoting healthy bowel movements and preventing constipation. However, urge suppression (choice B) is the behavior that directly contributes to constipation in this scenario.
3. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?
- A. Perform palpation before auscultation
- B. Perform percussion before auscultation
- C. Perform palpation after auscultation
- D. Perform inspection after auscultation
Correct answer: C
Rationale: The correct answer is C: Perform palpation after auscultation. When conducting an abdominal assessment, the correct sequence is inspection, auscultation, percussion, and then palpation. Inspecting the abdomen allows the nurse to observe any visible abnormalities, followed by listening for bowel sounds during auscultation. Percussion helps assess the density of abdominal contents before palpation for tenderness, masses, or organ enlargement. Choices A, B, and D are incorrect because palpation should always come last in the sequence of an abdominal assessment.
4. A nurse is monitoring a client who has been receiving intermittent enteral feedings. What should the nurse identify as an intolerance to the feeding?
- A. Increased appetite
- B. Nausea
- C. Weight gain
- D. Regular bowel movements
Correct answer: B
Rationale: Nausea is a common sign of intolerance to enteral feedings. When a client experiences nausea, it can indicate difficulty in tolerating the feeding formula. This intolerance may also manifest as vomiting and dumping syndrome. Choices A, C, and D are incorrect because increased appetite, weight gain, and regular bowel movements are not typical signs of intolerance to enteral feedings.
5. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which of the following types of immunity?
- A. Innate immunity
- B. Passive immunity
- C. Acquired immunity
- D. Natural immunity
Correct answer: C
Rationale: Immunizations provide acquired immunity. They work by introducing antigens into the body, which triggers the immune system to produce antibodies specific to that antigen. Choice A, 'Innate immunity,' refers to the natural defense mechanisms an organism is born with and does not involve immunizations. Choice B, 'Passive immunity,' is the transfer of pre-formed antibodies and does not involve immunizations. Choice D, 'Natural immunity,' is a general term that encompasses all immunity that is not acquired through deliberate immunization or passive transfer of antibodies.
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