ATI RN
RN ATI Capstone Proctored Comprehensive Assessment 2019 B
1. A client has a new prescription for guaifenesin. What information regarding the action of guaifenesin should the nurse include in the teaching?
- A. Decreases mucus production
- B. Reduces nasal congestion
- C. Increases cough production
- D. Reduces fever
Correct answer: C
Rationale: The correct answer is C: 'Increases cough production.' Guaifenesin is an expectorant that works by increasing cough production to help clear secretions from the airways. Option A is incorrect because guaifenesin does not decrease mucus production but rather helps to make the mucus easier to cough up. Option B is incorrect as guaifenesin does not reduce nasal congestion. Option D is incorrect because guaifenesin does not have any effect on reducing fever.
2. A healthcare professional is assessing a client who has a hip fracture. Which of the following findings should the healthcare professional expect?
- A. Hip pallor
- B. Leg abduction
- C. Muscle spasms
- D. Leg lengthening
Correct answer: C
Rationale: Muscle spasms are a common finding in clients with hip fractures. The muscle spasms occur due to the body's natural response to the injury, causing involuntary contractions. Hip pallor (Choice A) is not typically associated with hip fractures. Leg abduction (Choice B) and leg lengthening (Choice D) are not typical findings in clients with hip fractures, as the fracture usually results in limited range of motion and shortening of the affected limb.
3. A patient is on contact precautions for an infection. What is the most important action for the nurse to take?
- A. Wear gloves when entering the patient's room.
- B. Place the patient in a private room.
- C. Use a dedicated blood pressure cuff for the patient.
- D. Dispose of all equipment in a biohazard bag.
Correct answer: A
Rationale: The most important action for the nurse to take when caring for a patient on contact precautions is to wear gloves when entering the patient's room. This is crucial in preventing the spread of infection from the patient to the healthcare provider and vice versa. Placing the patient in a private room may be necessary for airborne precautions but is not specifically related to contact precautions. Using a dedicated blood pressure cuff for the patient is important for preventing cross-contamination but is not the most critical action. Disposing of equipment in a biohazard bag is a standard procedure but is not the most important action in this scenario.
4. A nurse in the PACU is caring for a client who has received general anesthesia and has a manifestation of malignant hyperthermia. The nurse should expect to administer which of the following medications?
- A. Acetaminophen
- B. Ibuprofen
- C. Dantrolene
- D. Diazepam
Correct answer: C
Rationale: Corrected Rationale: Dantrolene is the medication of choice to treat malignant hyperthermia, a life-threatening reaction to general anesthesia. It works by inhibiting the release of calcium ions in skeletal muscle cells, preventing muscle contracture and hypermetabolism. Acetaminophen (Choice A) and ibuprofen (Choice B) are not indicated for treating malignant hyperthermia. Diazepam (Choice D) may be used to control muscle spasms but is not the first-line treatment for malignant hyperthermia.
5. A healthcare professional is reviewing the lab results of a client with liver disease. Which finding requires immediate intervention?
- A. Elevated bilirubin levels
- B. Low albumin levels
- C. Elevated ammonia levels
- D. Low hemoglobin levels
Correct answer: C
Rationale: Elevated ammonia levels in a client with liver disease can lead to hepatic encephalopathy, requiring immediate intervention. Ammonia is a neurotoxin that can cause cognitive impairment and altered mental status. Elevated bilirubin levels (Choice A) are common in liver disease but do not require immediate intervention. Low albumin levels (Choice B) and low hemoglobin levels (Choice D) are also common in liver disease but do not pose an immediate threat compared to elevated ammonia levels.
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