a nurse is reviewing the medical record of a client who has a new prescription for clozapine which of the following findings indicates a contraindicat
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment Form B

1. A healthcare provider is reviewing the medical record of a client who has a new prescription for clozapine. Which of the following findings indicates a contraindication to clozapine?

Correct answer: D

Rationale: A low WBC count (3,300/mm3) is a contraindication to clozapine because this medication can cause severe neutropenia. Neutropenia is a significant reduction in white blood cell count, increasing the risk of infections. Elevated fasting blood glucose, asthma, and hypertension are not direct contraindications to clozapine.

2. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

Correct answer: C

Rationale: The priority action for the nurse is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or issues, the nurse can address them effectively, provide education or support, and encourage the client to comply with the necessary postoperative care. This approach fosters a patient-centered care environment. Demonstrating how to use the spirometer (Choice A) may be important but is not the priority at this moment. Setting a realistic postoperative goal (Choice B) is relevant but not as immediate as understanding the client's refusal. Requesting a respiratory therapist (Choice D) can be considered later if needed, but the nurse's initial focus should be on understanding the client's perspective.

3. A client is being prepared for discharge after a stroke. Which of the following interventions should be included in the discharge plan to prevent complications?

Correct answer: D

Rationale: The correct answer is to provide education on proper medication management. Proper medication management is crucial in reducing the risk of stroke recurrence and ensuring the client adheres to the treatment plan. While physical therapy, incentive spirometer use, and daily ambulation are important aspects of stroke rehabilitation, they are not directly related to preventing complications during the discharge phase.

4. Which action by the nurse will help reduce the risk of venous thromboembolism (VTE) in a postoperative patient?

Correct answer: A

Rationale: The correct answer is to encourage early ambulation and leg exercises. By promoting early ambulation and leg exercises, blood flow is enhanced, reducing the risk of venous thromboembolism (VTE) in postoperative patients. Choice B, applying compression stockings, helps prevent VTE but is not as effective as early ambulation and exercises. Choice C, administering anticoagulants, is important in VTE prevention but does not directly address improving circulation through physical activity. Choice D, elevating the patient's legs, may be beneficial for circulation in specific cases but is not as effective in preventing VTE as early ambulation and leg exercises.

5. The nurse is caring for a patient with an incision. Which actions will best indicate an understanding of medical and surgical asepsis for a sterile dressing change?

Correct answer: C

Rationale: Choice C is the correct answer. When performing a sterile dressing change, it is essential to use clean gloves to remove soiled dressings and sterile gloves and supplies for applying the new dressing. This helps maintain aseptic technique and reduce the risk of introducing pathogens to the wound. Choices A, B, and D involve incorrect use of sterile and clean supplies, which can compromise the sterility of the procedure and increase the risk of infection.

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