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PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is providing discharge teaching to a client with a new prescription for furosemide. Which client statement indicates a need for further teaching?
- A. I will take my morning pills with food or milk.
- B. I will weigh myself every day.
- C. I will notify the nurse if I have muscle cramps.
- D. I will limit my intake of fish.
Correct answer: D
Rationale: The correct answer is D. Furosemide is a diuretic that does not require a reduction in fish consumption. Therefore, the statement 'I will limit my intake of fish' indicates a misunderstanding of dietary considerations. Choices A, B, and C are all appropriate actions related to furosemide therapy. Taking pills with food or milk can help reduce stomach upset, daily weight monitoring is crucial due to the diuretic effect of furosemide, and notifying the nurse about muscle cramps is important as it can be a sign of electrolyte imbalance, a potential side effect of furosemide.
2. A nurse is caring for a client with a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?
- A. Tidaling with spontaneous respirations
- B. Drainage collection chamber is 1/3 full
- C. 1 cm of water present in the water seal chamber
- D. Suction chamber pressure of -20 cm H2O
Correct answer: C
Rationale: 1 cm of water in the water seal chamber is insufficient to ensure proper functioning of the chest tube. The water seal chamber typically requires a water level of 2 cm. Tidaling with spontaneous respirations (choice A) is an expected finding indicating proper functioning. Having the drainage collection chamber 1/3 full (choice B) is within the normal range. A suction chamber pressure of -20 cm H2O (choice D) is an appropriate level for chest tube drainage.
3. 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.
4. 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.
5. A nurse is planning care for four clients. Which client is the highest priority?
- A. Client with dry, black eschar on the heel
- B. Client wearing an arm cast and reporting numb fingers
- C. Client with reddened skin around the coccyx
- D. Client with frequent incontinence
Correct answer: B
Rationale: The correct answer is B because numb fingers indicate neurovascular compromise, which can lead to serious complications if not addressed promptly. The priority in this situation is to assess and address any circulation issues affecting the extremity. Choices A, C, and D are of concern but not as immediate as neurovascular compromise, which requires urgent attention to prevent further complications.
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