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PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A healthcare professional is assessing a client for signs of respiratory distress. Which of the following findings should the healthcare professional look for?
- A. Shallow breathing
- B. Bradycardia
- C. Increased appetite
- D. Warm, dry skin
Correct answer: A
Rationale: Corrected Question: A healthcare professional is assessing a client for signs of respiratory distress. Shallow breathing is a key indicator of respiratory distress, reflecting an inadequate exchange of oxygen and carbon dioxide. Bradycardia (Choice B) refers to a slow heart rate and is not typically a direct sign of respiratory distress. Increased appetite (Choice C) and warm, dry skin (Choice D) are unrelated to respiratory distress. Therefore, the correct answer is A.
2. A nurse is teaching a client about the use of nitrofurantoin. Which of the following should be included?
- A. It can cause a brown discoloration of urine
- B. It should be taken with food
- C. It has no side effects
- D. It is safe during pregnancy
Correct answer: A
Rationale: The correct answer is A. Nitrofurantoin can cause a harmless brown discoloration of urine. Choice B is also correct as it should be taken with food to enhance absorption. Choice C is incorrect as nitrofurantoin does have side effects, such as gastrointestinal disturbances. Choice D is incorrect as nitrofurantoin is not recommended during the last month of pregnancy due to potential risks to the fetus.
3. A nurse is caring for a client who is in the third trimester of pregnancy and has gestational diabetes. Which of the following complications is the fetus at risk for?
- A. Macrosomia
- B. Hydrocephalus
- C. Cleft palate
- D. Spina bifida
Correct answer: A
Rationale: The correct answer is A: Macrosomia. Gestational diabetes can result in fetal macrosomia, a condition where the baby grows larger than normal due to excess glucose in the mother's blood. This increases the risk of complications during delivery. Choices B, C, and D are incorrect. Hydrocephalus is an abnormal accumulation of cerebrospinal fluid within the brain. Cleft palate is a congenital condition where there is a split or opening in the roof of the mouth. Spina bifida is a neural tube defect characterized by the incomplete development of the spinal cord or its coverings.
4. A nurse is providing discharge teaching for a client newly prescribed methadone. Which statement 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 taking this medication.
- D. I’ll change positions slowly to prevent dizziness.
Correct answer: B
Rationale: The correct answer is B. Trouble sleeping is not a typical side effect of methadone; the nurse should clarify this misunderstanding. Choices A, C, and D are all correct statements regarding methadone. Methadone can indeed slow breathing, so it is important for the client to be aware of this effect. Avoiding alcohol while taking methadone is crucial due to the increased risk of central nervous system depression when alcohol is combined with methadone. Additionally, changing positions slowly can help prevent dizziness, which can be a side effect of methadone.
5. A client who is 38 weeks pregnant with herpes simplex virus is admitted to labor and delivery. What question should the nurse ask?
- A. Do you have any active lesions?
- B. Have your membranes ruptured?
- C. How far apart are your contractions?
- D. Are you positive for beta strep?
Correct answer: A
Rationale: The correct question the nurse should ask the client who is 38 weeks pregnant with herpes simplex virus is 'Do you have any active lesions?' This is crucial because active herpes lesions may necessitate a cesarean delivery to prevent neonatal infection. Choice B, 'Have your membranes ruptured?' is related to assessing for the rupture of membranes, not specific to the client's herpes infection. Choice C, 'How far apart are your contractions?' is related to monitoring labor progress. Choice D, 'Are you positive for beta strep?' is related to group B streptococcus screening, which is important but not the priority in this scenario.
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