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PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A nurse is caring for a client who has been taking isoniazid and rifampin for 3 weeks for the treatment of active pulmonary tuberculosis (TB). The client reports his urine is an orange color. Which of the following statements should the nurse make?
- A. Stop taking the isoniazid for 3 days and the discoloration should go away.
- B. Rifampin can turn body fluids orange.
- C. I'll make an appointment for you to see the provider this afternoon.
- D. Isoniazid can cause bladder irritation.
Correct answer: B
Rationale: The correct answer is B: 'Rifampin can turn body fluids orange.' Rifampin is known to cause orange discoloration of body fluids, including urine. This side effect is harmless and does not indicate a need to stop the medication. Choice A is incorrect because stopping isoniazid will not resolve the orange urine discoloration caused by rifampin. Choice C is unnecessary at this point since the orange urine is a known side effect of rifampin and does not require an urgent provider visit. Choice D is incorrect because bladder irritation is not typically associated with isoniazid.
2. A nurse is providing discharge teaching to a client who has heart failure and a new prescription for digoxin 0.215 mg PO daily and furosemide 20 mg PO daily. Which of the following statements by the client indicates an understanding of the teaching?
- A. I know that blurred vision is something I will expect to happen while taking digoxin.
- B. I will measure my urine output each day and document it in my diary.
- C. I will skip a dose of my digoxin if my resting heart rate is below 72 beats per minute.
- D. I will eat fruits and vegetables that have high potassium content every day.
Correct answer: D
Rationale: Clients taking digoxin and furosemide are at risk for hypokalemia. Eating potassium-rich foods can help maintain normal potassium levels.
3. A nurse is providing teaching to a group of new parents about medications. The nurse should include that aspirin is contraindicated for children who have a viral infection due to the risk of developing which of the following adverse effects?
- A. Reye's syndrome
- B. Visual disturbances
- C. Diabetes mellitus
- D. Wilms' tumor
Correct answer: A
Rationale: The correct answer is A: Reye's syndrome. Aspirin use in children with viral infections has been associated with Reye's syndrome, a serious condition that causes swelling in the liver and brain. Visual disturbances (choice B) are not typically associated with aspirin use in children with viral infections. Diabetes mellitus (choice C) and Wilms' tumor (choice D) are not adverse effects of aspirin use in this context.
4. A nurse is preparing to administer an enteral tube feeding through an NG tube at 250 mL over 4 hr. The nurse should set the pump to deliver how many mL/hr? (Round the answer to the nearest whole number)
- A. 63 mL/hr
- B. 36 mL/hr
- C. 78 mL/hr
- D. 90 mL/hr
Correct answer: A
Rationale: To calculate the rate for the enteral tube feeding, divide the total volume by the total time: 250 mL / 4 hr = 62.5 ≈ 63 mL/hr. Therefore, the nurse should set the pump to deliver 63 mL/hr. Choices B, C, and D are incorrect as they do not match the correct calculation result. B is too low, C is too high, and D is also too high based on the correct calculation.
5. A nurse is administering insulin glulisine 10 units subcutaneously at 0730 to an adolescent client who has type 1 diabetes mellitus. The nurse should anticipate the onset of action of the insulin at which of the following times?
- A. 0745
- B. 0700
- C. 0645
- D. 0457
Correct answer: A
Rationale: Insulin glulisine has a rapid onset of action, typically around 15 minutes. Therefore, the nurse should expect the onset around 0745. Choice A is correct as it aligns with the expected onset time. Choices B, C, and D are incorrect as they do not match the typical onset time of insulin glulisine.
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