a nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate the nurse should monitor the client for which of the fol
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PN ATI Capstone Proctored Comprehensive Assessment Form B

1. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate. The nurse should monitor the client for which of the following findings as an indication of magnesium toxicity?

Correct answer: A

Rationale: The correct answer is A: Decreased deep tendon reflexes. Magnesium sulfate toxicity can lead to diminished deep tendon reflexes, respiratory depression, and decreased urine output. Diminished deep tendon reflexes are an early sign of magnesium toxicity and indicate the need to discontinue the infusion. Elevated blood pressure (choice B) is not typically associated with magnesium toxicity. Increased urinary output (choice C) is also not a common finding in magnesium toxicity. Hyperreflexia (choice D) is not consistent with the expected findings of magnesium toxicity, which typically causes decreased reflexes.

2. A healthcare provider is providing education on the use of clozapine. Which of the following should be included?

Correct answer: A

Rationale: Correct Answer: A nurse should include monitoring for agranulocytosis when educating a patient about clozapine. Clozapine is known to cause agranulocytosis, a potentially life-threatening decrease in white blood cells. This adverse effect requires close monitoring to detect it early. Choices B, C, and D are incorrect because clozapine is not a first-line treatment for most conditions, it is more commonly associated with weight gain rather than weight loss, and it is known to have a risk for metabolic syndrome.

3. A nurse is caring for a toddler diagnosed with respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

Correct answer: A

Rationale: Using a designated stethoscope is the correct action when caring for a toddler diagnosed with RSV. This measure helps prevent the spread of infection to other clients by reducing the risk of contamination. Wearing an N95 respirator mask is not necessary for routine care of a toddler with RSV unless performing aerosol-generating procedures. Removing the disposable gown after leaving the toddler's room is important for infection control but not specific to RSV care. Placing the toddler in a room with negative air pressure is not a standard practice for managing RSV in toddlers.

4. A nurse is teaching a group of assistive personnel (AP) about caring for clients with Alzheimer's disease. Which of the following information should the nurse include in the teaching?

Correct answer: D

Rationale: The correct answer is D because clients with Alzheimer's disease can be prone to wandering and getting lost. Providing supervision can help prevent injuries and ensure their safety. Choices A, B, and C are incorrect because explaining procedures clearly, encouraging varied activities, and using simple communication are important but not specifically focused on the safety aspect of preventing clients from getting lost or injured.

5. A nurse is preparing to administer a dose of enoxaparin. Which of the following actions should the nurse take?

Correct answer: C

Rationale: The correct answer is to give enoxaparin in the abdomen. Enoxaparin is usually administered subcutaneously in the abdomen to avoid muscle irritation. Choice A is incorrect because enoxaparin should not be administered intramuscularly. Choice B is incorrect as monitoring APTT levels is not directly related to administering enoxaparin. Choice D is incorrect as enoxaparin should be administered slowly to prevent bruising or bleeding at the injection site.

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