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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is reviewing a prescription for doxazosin with a client. Which instruction should the nurse include?
- A. Decrease caloric intake to reduce weight gain
- B. Increase dietary fiber to prevent constipation
- C. Rise slowly when sitting up
- D. Take this medication each morning
Correct answer: C
Rationale: The correct answer is C: 'Rise slowly when sitting up.' Doxazosin can cause orthostatic hypotension, a sudden drop in blood pressure when standing up, leading to dizziness or fainting. Instructing the client to rise slowly helps prevent this adverse effect. Choices A, B, and D are incorrect. A decrease in caloric intake to reduce weight gain, an increase in dietary fiber to prevent constipation, and taking the medication each morning are not specific instructions related to managing the side effects of doxazosin.
2. A nurse is reviewing the ABG results of a client with chronic emphysema. Which result suggests the need for further treatment?
- A. PaO2 level of 89 mm Hg
- B. PaCO2 level of 55 mm Hg
- C. HCO3 level of 25 mEq/L
- D. pH level of 7.37
Correct answer: B
Rationale: The correct answer is B. A PaCO2 level of 55 mm Hg is elevated, indicating carbon dioxide retention, a common complication of emphysema that necessitates intervention. Elevated PaCO2 can lead to respiratory acidosis, reflecting inadequate ventilation. Choices A, C, and D are within normal ranges. A PaO2 level of 89 mm Hg is acceptable. An HCO3 level of 25 mEq/L falls within the normal range, suggesting adequate compensation. A pH level of 7.37 is also within the normal range, indicating the client's acid-base balance is maintained.
3. A nurse is assessing a 1-hour postpartum client and notes a boggy uterus located 2 cm above the umbilicus. Which of the following actions should the nurse take first?
- A. Take vital signs
- B. Assess lochia
- C. Massage the fundus
- D. Give oxytocin IV bolus
Correct answer: C
Rationale: When a nurse assesses a 1-hour postpartum client with a boggy uterus located 2 cm above the umbilicus, it indicates uterine atony. The first action the nurse should take is to massage the fundus. Fundal massage helps stimulate uterine contractions, which will reduce bleeding and prevent postpartum hemorrhage. Taking vital signs, assessing lochia, or administering an oxytocin IV bolus are important interventions but should come after addressing uterine atony through fundal massage.
4. A nurse is assessing a 2-hour-old newborn for cold stress. Which of the following findings should the nurse expect?
- A. Respiratory rate of 60/min
- B. Jitteriness of the hands
- C. Diaphoresis
- D. Bounding peripheral pulses
Correct answer: B
Rationale: The correct answer is B: Jitteriness of the hands. Jitteriness is a key sign of cold stress in a newborn, indicating the need for immediate warming measures. A respiratory rate of 60/min may not be directly indicative of cold stress. Diaphoresis (excessive sweating) and bounding peripheral pulses are not typical findings associated with cold stress in newborns.
5. A client in respiratory distress who is on oxygen is being cared for by a nurse. What is the most appropriate short-term goal?
- A. Nasal cannula remains in place
- B. Client completes morning care
- C. Client verbalizes breathing improvement after lunch
- D. Client maintains oxygen saturation of 90% during the shift
Correct answer: D
Rationale: The correct answer is D because maintaining oxygen saturation of 90% is a specific, measurable short-term goal that ensures adequate oxygenation. Choice A is not a goal focused on the client's physiological status but rather on the equipment. Choice B is related to activities of daily living and does not address the respiratory distress issue. Choice C is subjective and may not reflect the actual physiological improvement in the client's condition.
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