a nurse is caring for a client who is receiving oxytocin iv for labor augmentation the clients contractions are occurring every 45 seconds what action a nurse is caring for a client who is receiving oxytocin iv for labor augmentation the clients contractions are occurring every 45 seconds what action
Logo

Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A client receiving oxytocin IV for labor augmentation is experiencing contractions every 45 seconds. What action should the nurse take?

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. Contractions occurring every 45 seconds indicate uterine hyperstimulation, which can pose risks to both the client and the fetus. By stopping the oxytocin infusion, the nurse can help prevent further complications. Choices B, C, and D are incorrect because increasing, decreasing, or maintaining the oxytocin infusion can exacerbate the uterine hyperstimulation and increase the risks associated with it.

2. A client is receiving continuous enteral feedings. Which of the following interventions should the nurse implement?

Correct answer: B

Rationale: The correct answer is B: Flush the feeding tube every 4 hours. Flushing the feeding tube every 4 hours is essential to maintain patency and prevent clogging, ensuring the client receives the prescribed enteral nutrition without interruption. This intervention helps prevent complications such as tube occlusion. Monitoring intake and output is important for assessing the client's hydration status but does not directly address tube patency. Measuring the client's temperature is essential for monitoring for signs of infection but is not directly related to tube maintenance. Changing the feeding bag and tubing every 72 hours is important for infection control but does not address tube patency.

3. A client with chronic obstructive pulmonary disease (COPD) is being taught by a nurse about measures to improve breathing. Which of the following instructions should the nurse include?

Correct answer: A

Rationale: The correct instruction the nurse should include is to 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a technique that helps improve breathing efficiency in individuals with COPD by preventing airway collapse and allowing for better air exchange. Choice B is incorrect because breathing deeply and quickly can lead to hyperventilation and worsen symptoms in COPD patients. Choice C is incorrect because the incentive spirometer is a device used to encourage deep breathing and improve lung function, so it should not be avoided. Choice D is incorrect because physical activity is important for maintaining overall health and should be encouraged in a controlled and appropriate manner for individuals with COPD.

4. A nurse is preparing to administer a client's first dose of a new antibiotic. Which of the following is the priority nursing action?

Correct answer: A

Rationale: Assessing allergies before administering a new medication is crucial as it helps prevent potentially life-threatening allergic reactions like anaphylaxis. While monitoring vital signs and informing the client of side effects are important nursing actions, assessing allergies takes precedence to ensure the client's safety. Informed consent is necessary for the treatment process, but assessing allergies is the priority before administering any new medication.

5. A 50-year-old man presents with fatigue, arthralgia, and darkening of the skin. Laboratory tests reveal elevated liver enzymes and high serum ferritin levels. What is the most likely diagnosis?

Correct answer: B

Rationale: The symptoms of fatigue, arthralgia, and skin darkening, along with elevated liver enzymes and high serum ferritin levels, are characteristic of hemochromatosis, a condition characterized by iron overload. In hemochromatosis, excess iron is deposited in various organs, including the liver, leading to symptoms such as fatigue, joint pain, and skin pigmentation changes. The elevated liver enzymes and high serum ferritin levels seen in this patient further support the diagnosis of hemochromatosis.

Similar Questions

A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I). In planning the discharge teaching, the client should be cautioned by the nurse about which of the following?
The charge nurse observes that a client with a nasogastric tube on low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel (UAP) left the room. What action should the nurse take?
A client is undergoing radiation therapy. Which of the following actions should the nurse take to prevent skin irritation?
A nurse is developing discharge care plans for a client who has osteoporosis. To prevent injury, the nurse should instruct the client to:
A client diagnosed with major depressive disorder refuses to get out of bed, eat, or participate in group therapy. Which intervention is most important for the nurse to implement?

Access More Features

ATI Basic

  • 50,000 Questions with answers
  • All ATI courses Coverage
    • 30 days access @ $69.99

ATI Basic

  • 50,000 Questions with answers
  • All ATI courses Coverage
    • 90 days access @ $149.99