a nurse is providing teaching to a client with a new diagnosis of diabetes mellitus which instruction should the nurse give to the client to monitor f
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PN ATI Capstone Proctored Comprehensive Assessment Form A

1. A nurse is providing teaching to a client with a new diagnosis of diabetes mellitus. Which instruction should the nurse give to the client to monitor for hypoglycemia?

Correct answer: B

Rationale: The correct answer is B: 'Monitor for diaphoresis.' Diaphoresis, which refers to excessive sweating, is a common symptom of hypoglycemia. It indicates a low blood sugar level and should prompt immediate treatment. Polyuria (excessive urination), abdominal pain, and thirst are not typically associated with hypoglycemia. Polyuria is more commonly linked to hyperglycemia, while abdominal pain and thirst are not specific symptoms of hypoglycemia.

2. A nurse is caring for a client who is in active labor. The nurse notes early decelerations in the FHR on the fetal monitor tracing. The nurse should identify that which of the following conditions causes early decelerations in the FHR?

Correct answer: D

Rationale: Early decelerations are caused by head compression during contractions, which is a normal response as the fetal head is being compressed during uterine contractions. This usually indicates that the fetus is descending into the birth canal. Choices A, B, and C are incorrect. Fetal hypoxemia, cord compression, and uteroplacental insufficiency typically present with variable or late decelerations on the fetal heart rate tracing, not early decelerations.

3. A healthcare professional is preparing to administer an IM injection to a 4-month-old infant. Which of the following injection sites should the healthcare professional use?

Correct answer: D

Rationale: The vastus lateralis is the preferred site for IM injections in infants under 1 year of age because it is well developed and easily accessible compared to other muscle groups. The ventrogluteal and deltoid sites are not typically used for infants due to muscle development and size. The dorsogluteal site is not recommended for infants or young children due to its proximity to major nerves and blood vessels.

4. A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. Which of the following medications should the nurse plan to administer?

Correct answer: C

Rationale: The correct answer is C: Vitamin B6 (pyridoxine). Vitamin B6 is often used to treat nausea and vomiting in pregnancy, including hyperemesis gravidarum. It is considered safe for use in pregnant clients. Digoxin (Choice A) is a medication used for heart conditions, not for hyperemesis gravidarum. Calcium gluconate (Choice B) is used to treat calcium deficiencies, not nausea and vomiting in pregnancy. Propranolol (Choice D) is a beta-blocker used for conditions like hypertension and anxiety, not for hyperemesis gravidarum.

5. A client at 28 weeks of gestation is experiencing preterm labor. Which of the following medications should the nurse plan to administer?

Correct answer: B

Rationale: Nifedipine is the correct choice in this scenario. It is a calcium channel blocker that helps suppress uterine contractions and halt preterm labor. Nifedipine is commonly used to manage preterm labor in pregnant women by relaxing the smooth muscle of the uterus. Oxytocin (Choice A) is used to induce or augment labor, not to inhibit contractions. Dinoprostone (Choice C) and Misoprostol (Choice D) are prostaglandins used for cervical ripening and induction of labor, not for stopping preterm labor.

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