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PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A client with staphylococcus epidermidis is prescribed vancomycin. Identify the adverse effect associated with this antibiotic therapy.
- A. Hepatotoxicity
- B. Constipation
- C. Infusion reaction
- D. Immunosuppression
Correct answer: C
Rationale: The correct adverse effect associated with vancomycin therapy is an infusion reaction, known as Red Man Syndrome. This reaction presents with rashes, flushing, tachycardia, and hypotension. It is essential to administer vancomycin over at least 60 minutes to prevent these symptoms. Hepatotoxicity, constipation, and immunosuppression are not commonly associated with vancomycin use. Ototoxicity and renal toxicity are significant risks with prolonged vancomycin therapy.
2. A nurse is reviewing the medication metformin with a client who has diabetes. Which of the following side effects should the nurse discuss?
- A. Gastrointestinal upset
- B. Increased appetite
- C. Weight loss
- D. Frequent urination
Correct answer: A
Rationale: The correct answer is A: Gastrointestinal upset. Metformin can cause gastrointestinal upset, especially when first starting therapy. It is important to take it with food to reduce these effects. Increased appetite (choice B) and weight loss (choice C) are not common side effects of metformin but may occur due to improved blood sugar control. Frequent urination (choice D) is a symptom of uncontrolled diabetes and not a side effect of metformin.
3. 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?
- A. I understand that I can change my mind at any time.
- B. I have a living will that outlines my wishes when I am unable to make a decision.
- C. I need to inform my family about my wishes.
- D. I don’t need to worry about advance directives right now.
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.
4. A healthcare provider is assessing a client for allergies before administering propofol. Which of the following allergies is a contraindication to the medication?
- A. Eggs
- B. Milk
- C. Shrimp
- D. Peanuts
Correct answer: A
Rationale: The correct answer is A: Eggs. Propofol is contraindicated in clients with egg allergies because it contains egg lecithin, which can trigger allergic reactions in sensitive individuals. Milk, shrimp, and peanuts are not contraindications for propofol administration.
5. A nurse is assessing a client for signs of anemia. Which of the following findings should the nurse look for?
- A. Increased energy
- B. Pale skin
- C. Elevated blood pressure
- D. Weight gain
Correct answer: B
Rationale: The correct answer is B: 'Pale skin.' Pale skin is a common sign of anemia due to reduced hemoglobin levels, which affects the skin color. Anemia is characterized by a decrease in the number of red blood cells or hemoglobin in the blood, leading to a paler complexion. Choices A, C, and D are incorrect. 'Increased energy' is not typically associated with anemia, as fatigue is a common symptom. 'Elevated blood pressure' is not a typical finding in anemia; instead, anemia may cause hypotension. 'Weight gain' is not a direct symptom of anemia; in fact, weight loss may occur in some cases due to reduced appetite or other factors associated with anemia.
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