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PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A healthcare professional is preparing to administer a dose of naloxone. Which of the following should the healthcare professional assess?
- A. Heart rate
- B. Respiratory rate
- C. Blood pressure
- D. Temperature
Correct answer: B
Rationale: Correct. Naloxone is used to reverse opioid overdose, which can cause respiratory depression. Assessing the respiratory rate before administering naloxone is crucial to monitor the patient's breathing. Choices A, C, and D are important assessments in general patient care but are not specifically crucial before administering naloxone for opioid overdose.
2. A nurse is caring for a client prescribed prednisone. Which of the following should the nurse monitor?
- A. Blood glucose levels
- B. Serum potassium levels
- C. Liver function tests
- D. Heart rate
Correct answer: A
Rationale: Corrected Rationale: Prednisone is known to cause hyperglycemia by increasing blood glucose levels. Monitoring blood glucose levels is crucial to detect and manage any potential hyperglycemic effects of prednisone. While prednisone can also affect serum potassium levels and liver function, the priority monitoring parameter in this case is blood glucose levels. Monitoring heart rate is not directly associated with prednisone administration, making it a less relevant parameter to monitor in this scenario.
3. A client is being educated by a nurse about the use of bupropion. Which of the following should be included?
- A. It can cause weight gain
- B. It may increase seizure risk
- C. It is an SSRI
- D. It has no side effects
Correct answer: B
Rationale: The correct answer is B. Bupropion may lower the seizure threshold, increasing the risk of seizures, especially in clients with a history of seizures. Choice A is incorrect because bupropion is associated with weight loss rather than weight gain. Choice C is incorrect as bupropion is not an SSRI; it is an aminoketone antidepressant. Choice D is incorrect as bupropion, like all medications, can have side effects, and it is essential for clients to be aware of them.
4. A client is found on the floor of their room experiencing a seizure. Which action is the nurse's priority?
- A. Restrain the client
- B. Place the client on their side with their head forward
- C. Perform a neurological assessment
- D. Monitor the client's vitals every 2 minutes
Correct answer: B
Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration of fluids or secretions. Restraint should never be used during a seizure as it can cause harm to the client. Performing a neurological assessment is important but not the immediate priority during an active seizure. While monitoring vitals is essential, ensuring the client's airway is clear takes precedence.
5. A nurse is preparing to administer a dose of enalapril. Which of the following should the nurse assess first?
- A. Heart rate
- B. Blood pressure
- C. Serum creatinine
- D. Potassium levels
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.
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