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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is preparing to teach a client with chronic renal failure. Which dietary instruction is most appropriate?
- A. Increase calcium intake
- B. Increase potassium intake
- C. Increase protein intake
- D. Restrict protein intake
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.
2. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which action should the nurse take if the client develops toxicity?
- A. Administer calcium gluconate IV
- B. Increase the magnesium sulfate infusion
- C. Administer IV fluids
- D. Administer hydralazine
Correct answer: A
Rationale: In cases of magnesium sulfate toxicity, administering calcium gluconate IV is crucial as it is the antidote for magnesium sulfate. Calcium gluconate helps reverse the effects of magnesium sulfate, especially when signs of toxicity like respiratory depression or loss of reflexes occur. Increasing the magnesium sulfate infusion would worsen toxicity. Administering IV fluids may be beneficial for hydration but does not address magnesium sulfate toxicity. Hydralazine is used to manage hypertension, not magnesium sulfate toxicity.
3. A nurse is planning care for an adolescent client with chronic renal failure. Which action should the nurse include?
- A. Encourage a diet high in calcium
- B. Provide a diet high in potassium
- C. Ensure increased fluid intake
- D. Restrict protein intake to the RDA
Correct answer: D
Rationale: In chronic renal failure, it is essential to restrict protein intake to the Recommended Dietary Allowance (RDA) to reduce the accumulation of waste products that the kidneys can no longer effectively eliminate. Choices A, B, and C are incorrect because in chronic renal failure, high calcium, high potassium, and increased fluid intake can further strain the kidneys and worsen the condition.
4. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate. Which of the following is an indication of magnesium toxicity?
- A. Blood glucose of 160 mg/dL
- B. Urine output of 20 mL/hour
- C. Systolic BP of 140 mm Hg
- D. Respiratory rate of 20/min
Correct answer: B
Rationale: The correct answer is B: Urine output of 20 mL/hour. Urine output below 30 mL/hour is a sign of magnesium toxicity due to the risk of accumulation in the body. Choices A, C, and D are not indicative of magnesium toxicity. Elevated blood glucose, systolic blood pressure, and normal respiratory rate are not specific signs of magnesium toxicity.
5. A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?
- A. Take vital signs
- B. Assess lochia
- C. Massage the fundus
- D. Give oxytocin IV bolus
Correct answer: C
Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.
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