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PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is caring for a client who has been prescribed methadone. Which of the following client statements indicates a need for further teaching?
- A. I understand methadone slows my breathing.
- B. I understand methadone may cause me to have trouble sleeping.
- C. I will avoid alcohol while I’m taking this medication.
- D. I’ll change positions slowly, especially when standing.
Correct answer: B
Rationale: The correct answer is B because methadone typically causes sedation and respiratory depression, not trouble sleeping. The statement about trouble sleeping indicates a need for further teaching. Choices A, C, and D are incorrect because understanding that methadone slows breathing, avoiding alcohol while taking the medication, and changing positions slowly to prevent dizziness are all appropriate client statements when prescribed methadone.
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 providing teaching for a child who is prescribed ferrous sulfate. Which of the following instructions should the nurse include?
- A. Take the medication with milk
- B. Take with a glass of orange juice
- C. Take at bedtime
- D. Take with meals
Correct answer: B
Rationale: The correct answer is B: 'Take with a glass of orange juice.' Ferrous sulfate should be taken with orange juice (vitamin C) to enhance the absorption of iron. Taking it with milk (choice A) is not recommended as calcium can interfere with iron absorption. Taking it at bedtime (choice C) or with meals (choice D) may lead to decreased absorption due to interactions with other food or medications.
4. A client newly prescribed sertraline is being taught by a nurse. Which statement by the client indicates understanding?
- A. I should take this medication with meals.
- B. I might have trouble sleeping when I start this medication.
- C. I should avoid drinking orange juice.
- D. I will feel better immediately after starting the medication.
Correct answer: B
Rationale: Choice B, 'I might have trouble sleeping when I start this medication,' indicates understanding because insomnia is a common side effect of sertraline, especially when initiating the medication. This statement shows the client comprehends a potential adverse effect and is prepared for it. Choices A, C, and D are incorrect. Taking sertraline with or without meals does not significantly affect its efficacy. There is no specific contraindication about drinking orange juice while on sertraline. Feeling better immediately after starting the medication is unlikely as sertraline usually takes some time to exert its therapeutic effects.
5. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which action should the nurse take?
- A. Massage the affected extremity
- B. Elevate the affected leg
- C. Apply cold packs to the affected leg
- D. Keep the leg dependent to increase circulation
Correct answer: B
Rationale: Elevating the leg promotes venous return and reduces swelling, which is crucial for clients with DVT. Massaging the affected extremity can dislodge the clot and worsen the condition. Applying cold packs can cause vasoconstriction, potentially increasing the risk of clot formation. Keeping the leg dependent can impede circulation and increase the risk of clot migration.
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