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PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A client has been prescribed ferrous sulfate. Which instruction should the nurse provide to the client?
- A. Avoid strawberries, citrus fruits, and melon to improve absorption
- B. Take with fluids other than coffee or tea
- C. Take on a full stomach
- D. Double the dose if you miss a dose one day
Correct answer: B
Rationale: The correct instruction the nurse should provide to a client prescribed ferrous sulfate is to take it with fluids other than coffee or tea. Coffee and tea can inhibit iron absorption. Therefore, choices A, C, and D are incorrect. Avoiding strawberries, citrus fruits, and melon is not necessary for improving absorption of ferrous sulfate, taking it on a full stomach is not recommended, and doubling the dose if a dose is missed can lead to an overdose.
2. A client who is at 24 weeks of gestation is being taught about the signs of preterm labor. Which of the following should the nurse include?
- A. Sudden weight loss
- B. Regular contractions
- C. Shortness of breath
- D. Vaginal spotting
Correct answer: B
Rationale: The correct answer is B: Regular contractions. Regular contractions before 37 weeks of gestation are a significant sign of preterm labor. It is essential for clients to be aware of this symptom and report it promptly to their healthcare provider. Choices A, C, and D are incorrect because sudden weight loss, shortness of breath, and vaginal spotting are not typical signs of preterm labor. Teaching clients about the specific signs of preterm labor can help in early detection and intervention, ultimately improving outcomes for both the client and the baby.
3. A nurse is teaching a client with newly diagnosed hypertension about lifestyle changes. Which of the following recommendations should the nurse make?
- A. Limit sodium intake to 3,000 mg per day.
- B. Exercise for at least 30 minutes most days of the week.
- C. Drink no more than two alcoholic drinks per day.
- D. Increase fluid intake to at least 3 liters per day.
Correct answer: B
Rationale: The correct answer is B: 'Exercise for at least 30 minutes most days of the week.' Regular exercise, especially aerobic activity, is known to help lower blood pressure and should be included in lifestyle changes for managing hypertension. Choice A is incorrect because the recommended sodium intake for individuals with hypertension is usually lower than 3,000 mg per day. Choice C is incorrect as it is advisable to limit alcohol intake to one drink per day for women and two drinks per day for men. Choice D is incorrect because increasing fluid intake to 3 liters per day may not be necessary and could be harmful in some cases, depending on the individual's health status.
4. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client has a productive cough and is started on airborne precautions. Which of the following interventions should the nurse implement?
- A. Wear an N95 respirator mask when caring for the client.
- B. Place the client in a semi-private room.
- C. Have the client wear a surgical mask during meals.
- D. Use a negative pressure air filtration system.
Correct answer: A
Rationale: The correct answer is to wear an N95 respirator mask when caring for the client with TB. This is crucial to prevent the nurse from inhaling the airborne particles that spread the infection. Choice B is incorrect because placing the client in a semi-private room does not address the protection of the nurse. Choice C is incorrect as having the client wear a surgical mask during meals is not sufficient to protect the nurse during all interactions. Choice D is incorrect as using a negative pressure air filtration system is more applicable to airborne infection isolation rooms in healthcare settings and not a standard intervention for nurses caring for a single client with TB.
5. A healthcare professional is assessing a client with deep vein thrombosis (DVT). Which of the following interventions should the healthcare professional include in the plan of care?
- A. Apply ice packs to the affected extremity.
- B. Encourage ambulation every hour.
- C. Elevate the affected leg when in bed.
- D. Massage the affected area to improve circulation.
Correct answer: C
Rationale: Elevating the affected leg is a crucial intervention in the care of a client with deep vein thrombosis (DVT). This position helps reduce swelling and promotes venous return, which can alleviate symptoms associated with DVT. Applying ice packs (Choice A) may worsen the condition by causing vasoconstriction. Encouraging ambulation (Choice B) can dislodge the clot and lead to fatal complications. Massaging the affected area (Choice D) can also dislodge the clot and is contraindicated in DVT.
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