ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B with NGN
1. A client has a prescription for a clear liquid diet. Which of the following foods should the nurse allow the client to have?
- A. Lemon sherbet
- B. Milkshake
- C. Vanilla ice cream
- D. Grape juice
Correct answer: D
Rationale: Grape juice is the correct choice for a clear liquid diet because it is a liquid that is transparent and does not contain any solid particles. Lemon sherbet, milkshake, and vanilla ice cream are not appropriate for a clear liquid diet as they all contain solid particles or are not in liquid form.
2. Which of the following is an adverse effect of Lithium Carbonate that requires client education?
- A. Increased risk of infection
- B. Gastrointestinal distress
- C. Increased white blood cell count
- D. Nausea and vomiting
Correct answer: B
Rationale: The correct answer is B: Gastrointestinal distress. When taking Lithium Carbonate, clients may experience gastrointestinal distress as an adverse effect. It is crucial to educate clients about this potential side effect to help them manage it effectively. Choices A, C, and D are incorrect. Increased risk of infection (Choice A) is not a typical adverse effect of Lithium Carbonate. Similarly, increased white blood cell count (Choice C) is not associated with this medication's adverse effects. Nausea and vomiting (Choice D) are general side effects of many medications but are not specifically attributed to Lithium Carbonate.
3. How should a healthcare professional respond to a patient experiencing hypoglycemia?
- A. Rechecking the blood glucose level in 15 minutes
- B. Encouraging the patient to eat a high-protein snack
- C. Administering 15g of fast-acting carbohydrates
- D. Administering glucagon if the patient is unconscious
Correct answer: C
Rationale: The correct response to a patient experiencing hypoglycemia is to administer 15g of fast-acting carbohydrates. This helps quickly increase the blood glucose levels in the patient, addressing the low blood sugar. Rechecking the blood glucose level in 15 minutes (Choice A) may delay necessary intervention, encouraging a high-protein snack (Choice B) is not recommended as it does not rapidly increase blood sugar levels, and administering glucagon if the patient is unconscious (Choice D) is typically done in severe cases of hypoglycemia when the patient is unable to eat or drink.
4. A nurse is teaching a client about levothyroxine for primary hypothyroidism. Which of the following statements should the nurse use when teaching the client?
- A. Take this medication until your symptoms are gone and then discontinue
- B. Symptoms improve immediately after starting the medication
- C. The medication decreases the overproduction of the thyroid hormone thyroxine
- D. Tremors, nervousness, and insomnia may indicate your dose is too high
Correct answer: D
Rationale: Tremors, nervousness, and insomnia indicate that the dose may be too high, requiring a dose adjustment.
5. A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?
- A. Self-report of pain
- B. Nonverbal behavior
- C. Severity of the condition
- D. Vital signs
Correct answer: A
Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.
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