a nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous iv infusion which of the following client findings in
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Nursing Elites

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PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?

Correct answer: B

Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.

2. A nurse is caring for a client with a prescription for duloxetine. Which of the following should the nurse monitor?

Correct answer: A

Rationale: The correct answer is A) Liver function. Duloxetine can affect liver function, making it crucial for the nurse to monitor liver function tests. Monitoring serum electrolytes (choice B), blood glucose (choice C), or potassium levels (choice D) is not directly associated with duloxetine use and would not be the priority in this case.

3. A nurse has provided education to a client regarding prescribed levothyroxine sodium. Which of the following client statements demonstrates understanding of medication administration?

Correct answer: A

Rationale: The correct answer is A. Levothyroxine should be taken in the morning on an empty stomach to prevent insomnia and ensure proper absorption of the medication. Choice B is incorrect because taking levothyroxine at night may interfere with sleep and absorption. Choice C is incorrect as stopping the medication without consulting the healthcare provider can lead to negative health outcomes. Choice D is incorrect because levothyroxine is a daily medication that should be taken consistently, not just when symptoms are present.

4. A nurse observes an assistive personnel (AP) providing care to a child who is in skeletal traction. Which of the following actions requires intervention?

Correct answer: C

Rationale: The correct answer is C. Placing weights on the child's bed can alter the traction, which must remain constant to be effective. This action requires immediate intervention to prevent harm. Providing a high-protein snack (Choice A) is appropriate for the child's nutritional needs. Assisting the child to reposition (Choice B) helps prevent complications such as pressure ulcers. Massaging pressure points (Choice D) can help promote circulation and prevent skin breakdown. However, altering the traction by placing weights on the bed can be detrimental to the child's condition and must be corrected promptly.

5. A client is admitted for observation and has full range of motion. Which is the best manner to encourage the client to void?

Correct answer: D

Rationale: The correct answer is D: Client Bathroom. Encouraging the client to use the bathroom is the best way to promote independence and privacy, maintaining normal function. In this case, since the client has full range of motion, using the client bathroom would be the most appropriate choice. Options A, B, and C (Urinal, Bedpan, Bedside Commode) are not the best choices as they may restrict the client's independence and privacy, which can impact their psychological well-being and normal voiding function.

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