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PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is assessing a client who is at risk for falls. Which of the following findings should the nurse recognize as increasing the client's risk of falling?
- A. Normal gait
- B. Recent history of dizziness
- C. 20/20 vision
- D. Takes a multivitamin daily
Correct answer: B
Rationale: The correct answer is B: Recent history of dizziness. A recent history of dizziness significantly increases the risk of falling, as dizziness can impair balance and coordination. Having a normal gait (choice A) and 20/20 vision (choice C) are not factors that directly increase the risk of falling. Taking a multivitamin daily (choice D) does not inherently contribute to an increased risk of falling unless it causes dizziness as a side effect, which is not specified in the question.
2. A nurse is assessing a client who has a femur fracture and is in skeletal traction. Which of the following findings should the nurse report to the provider?
- A. Clear fluid drainage from the pin sites
- B. Client reporting intermittent muscle spasms
- C. Client reporting severe pain despite receiving analgesics
- D. The traction weights are hanging freely
Correct answer: C
Rationale: The correct answer is C. Severe pain that is not relieved by analgesics may indicate neurovascular compromise or other complications and requires immediate attention by the provider. Choices A, B, and D are incorrect because clear fluid drainage from the pin sites is expected in skeletal traction, intermittent muscle spasms are common in this situation, and traction weights hanging freely indicate proper traction alignment.
3. A client is being educated by a nurse on how to use a PCA pump postoperatively. Which statement by the client indicates understanding?
- A. I should wait until the pain is severe before using the PCA pump.
- B. My family can press the button for me while I’m asleep.
- C. I will press the button when I start to feel pain.
- D. I will only press the button once per hour.
Correct answer: C
Rationale: The correct answer is C. This statement indicates understanding because the client recognizes that they should use the PCA pump when they start to feel pain. Waiting for the pain to become severe is not recommended as it may lead to inadequate pain control. Option B is incorrect because only the client should control the PCA pump to ensure safety and appropriate dosing. Option D is also incorrect as there is no set limit on how often the button can be pressed, as it should be used as needed when pain is felt.
4. A nurse is caring for a client with congestive heart failure. Which of the following prescriptions should the nurse anticipate?
- A. Call the provider if the respiratory rate is less than 18/min
- B. Administer a 500 mL IV bolus of 0.9% sodium chloride over 1 hour
- C. Administer enalapril 2.5 mg PO twice daily
- D. Call the provider if the client’s pulse rate is less than 80/min
Correct answer: C
Rationale: Enalapril, an ACE inhibitor, is commonly prescribed to manage hypertension and heart failure. It helps reduce the workload on the heart and prevent fluid retention. Options A, B, and D are incorrect. Option A focuses on a respiratory rate, which is not specific to heart failure management. Option B suggests administering a large IV bolus of fluid, which can worsen heart failure by increasing fluid volume. Option D addresses the pulse rate, which is not a typical parameter to monitor for heart failure specifically.
5. A nurse is caring for a client with a recent diagnosis of myasthenia gravis. Which of the following medications should the nurse expect to administer?
- A. Methotrexate
- B. Pyridostigmine
- C. Baclofen
- D. Atropine
Correct answer: B
Rationale: Pyridostigmine is the drug of choice for treating myasthenia gravis because it enhances communication between nerves and muscles by inhibiting acetylcholinesterase. Methotrexate (choice A) is not indicated for myasthenia gravis but is used in conditions like rheumatoid arthritis. Baclofen (choice C) is a muscle relaxant used for conditions like spasticity. Atropine (choice D) is not typically used in myasthenia gravis as it can worsen muscle weakness.
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