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PN ATI Capstone Proctored Comprehensive Assessment Form B
1. During triage following a mass casualty event, which client should be prioritized?
- A. A client with massive head trauma
- B. A client with full-thickness burns to the face and trunk
- C. A client showing signs of hypovolemic shock
- D. A client with an open fracture of the lower extremity
Correct answer: C
Rationale: During triage after a mass casualty event, the client showing signs of hypovolemic shock should be prioritized. Hypovolemic shock is a life-threatening condition that requires immediate attention to restore circulation and prevent death. While clients with head trauma, burns, and fractures also need urgent care, hypovolemic shock poses an immediate threat to life and must be addressed first to stabilize the client's condition.
2. During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?
- A. A client with cystic fibrosis who has a productive cough and reports thirst
- B. A client with gastroenteritis who is lethargic and confused
- C. A client with diabetes mellitus whose blood glucose is 185 mg/dL
- D. A client with sickle cell anemia who reports pain 15 minutes after receiving analgesics
Correct answer: B
Rationale: Lethargy and confusion in a client with gastroenteritis are concerning findings that may indicate severe dehydration or electrolyte imbalance, requiring immediate intervention. While the other options are important, they do not pose an immediate life-threatening risk compared to the altered mental status in a client with gastroenteritis.
3. A client at 38 weeks gestation with a history of herpes simplex virus 2 is being admitted. Which of the following questions is most appropriate to ask the client?
- A. Have your membranes ruptured?
- B. Do you have any active lesions?
- C. Are you positive for beta strep?
- D. How far apart are your contractions?
Correct answer: B
Rationale: The most appropriate question to ask a client with a history of herpes simplex virus 2 at 38 weeks gestation is whether they have any active lesions. Active herpes lesions during labor can necessitate a cesarean delivery to prevent neonatal transmission. Asking about ruptured membranes (choice A), beta strep status (choice C), or contraction timing (choice D) is important but not the priority when managing a client with a history of herpes simplex virus 2 due to the high risk of neonatal transmission.
4. A client has been prescribed ferrous sulfate. Which instruction should the nurse include?
- A. Take with meals
- B. Take with a glass of orange juice
- C. Take at bedtime
- D. Take with milk
Correct answer: B
Rationale: The correct instruction for a client prescribed ferrous sulfate is to take it with a glass of orange juice. Vitamin C, found in orange juice, enhances the absorption of iron, making it more effective. Taking ferrous sulfate with meals, at bedtime, or with milk can decrease its absorption and effectiveness, so these options are incorrect.
5. A client who has osteoporosis is being discharged with a new prescription for alendronate. Which of the following instructions should the nurse provide?
- A. Take the medication at bedtime.
- B. Take the medication with a full glass of water.
- C. Take the medication with food.
- D. Lie down for 30 minutes after taking the medication.
Correct answer: B
Rationale: The correct answer is to take the medication with a full glass of water. Alendronate should be taken with a full glass of water to prevent esophageal irritation. Additionally, the client should remain upright for 30 minutes after taking it to prevent potential adverse effects. Choice A is incorrect because alendronate should not be taken at bedtime, but rather in the morning on an empty stomach. Choice C is incorrect because alendronate should be taken on an empty stomach, not with food. Choice D is incorrect because the client should remain upright, not lie down, for 30 minutes after taking the medication.
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