a nurse is caring for a client receiving oxytocin iv for labor augmentation the clients contractions are occurring every 45 seconds and lasting 90 sec
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is caring for a client receiving oxytocin IV for labor augmentation. The client’s contractions are occurring every 45 seconds and lasting 90 seconds. What action should the nurse take?

Correct answer: A

Rationale: In this scenario, the client is experiencing uterine hyperstimulation with contractions every 45 seconds lasting 90 seconds. This frequency and duration of contractions can lead to fetal distress. The appropriate nursing action is to discontinue the oxytocin infusion immediately to prevent complications. Increasing or maintaining the oxytocin infusion would exacerbate the situation, while decreasing it may not be sufficient to address the issue effectively.

2. A client is reviewing information about advance directives with a nurse. Which of the following statements by the client indicates an understanding of the teaching?

Correct answer: B

Rationale: The correct answer is B because having a living will indicates that the client understands and has documented their wishes regarding medical treatment when they are unable to make decisions. Choice A is incorrect because while it's true that clients can change their minds about advance directives, it doesn't specifically indicate an understanding of the teaching provided. Choice C is important but doesn't directly show if the client understands advance directives. Choice D is incorrect because it dismisses the importance of advance directives, indicating a lack of understanding.

3. When admitting a client with fever, confusion, and decreased level of consciousness, what should the nurse do first after obtaining the client's history and assessment?

Correct answer: A

Rationale: When a client presents with fever, confusion, and decreased level of consciousness, the first step should be to identify the client's needs. This involves recognizing any immediate concerns or issues that require urgent attention. Starting intravenous fluids, notifying the provider, or conducting a neurological assessment may be necessary actions but should come after identifying the client's needs to ensure proper prioritization of care.

4. A nurse is reviewing discharge instructions with the parents of a newborn. Which of the following statements indicates a need for further teaching?

Correct answer: D

Rationale: The correct answer is D. Leaving the baby's diaper off to prevent diaper rash is not recommended because it increases the risk of infection. Proper diaper hygiene and frequent diaper changes are more effective in preventing diaper rash. Choices A, B, and C are correct as placing the baby on its back to sleep, giving the baby a pacifier at bedtime, and keeping the baby's crib free of blankets and toys are appropriate measures to ensure the newborn's safety and reduce the risk of Sudden Infant Death Syndrome (SIDS).

5. A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend?

Correct answer: C

Rationale: The correct answer is C: 'Low fat diet.' A client with chronic cholecystitis should follow a low-fat diet to decrease the frequency of biliary colic episodes. Fats can trigger the release of cholecystokinin, which stimulates the gallbladder to contract, potentially causing pain in individuals with cholecystitis. Choices A, B, and D are incorrect. A low potassium diet is prescribed for individuals with specific kidney conditions or on certain medications. A high fiber diet is beneficial for conditions like constipation, diverticulosis, or to promote general bowel health. A low sodium diet is often recommended for conditions like hypertension or heart failure to reduce fluid retention.

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