PN ATI Capstone Proctored Comprehensive Assessment 2020 A

PN ATI Capstone Proctored Comprehensive Assessment 2020 A Related

Review PN ATI Capstone Proctored Comprehensive Assessment 2020 A related questions and content

A nurse is providing teaching to a newly licensed nurse about administering morphine via IV bolus to a client. Which of the following information should the nurse include in the teaching?

  • A. Respiratory depression can occur within 7 minutes after the morphine is administered.
  • B. The morphine will peak within a few minutes.
  • C. Withhold the morphine if the client has a respiratory rate less than 16/min.
  • D. Administer the morphine over 2 minutes.
Correct Answer: A

Rationale: The correct answer is A because respiratory depression is a significant risk when administering morphine, and it can occur within 7 minutes after administration. This information is crucial for the nurse to recognize and respond promptly. Choice B is incorrect because the peak effect of morphine via IV bolus is typically reached within a few minutes, not specifically 10 minutes. Choice C is incorrect because withholding morphine based solely on a respiratory rate less than 16/min may not be appropriate without considering other factors such as pain level, oxygen saturation, and overall respiratory status. Choice D is incorrect because administering morphine over 2 minutes may not prevent respiratory depression if it occurs rapidly after administration. Nurses should be vigilant for signs of respiratory depression regardless of the administration duration.

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A client is receiving IV gentamicin three times daily. Which of the following findings indicates that the client is experiencing an adverse effect of this medication?

  • A. Hypoglycemia
  • B. Proteinuria
  • C. Nasal congestion
  • D. Visual disturbances
Correct Answer: B

Rationale: The correct answer is B: Proteinuria. Proteinuria can indicate nephrotoxicity, a known adverse effect of gentamicin. Gentamicin is known to cause kidney damage, leading to proteinuria. Hypoglycemia is not typically associated with gentamicin use but may be related to insulin administration or other medical conditions. Nasal congestion is not a common adverse effect of gentamicin. Visual disturbances are also not typically reported with gentamicin use.

A healthcare professional is reviewing the laboratory results for a client who has a prescription for filgrastim. The healthcare professional should recognize that an increase in which of the following values indicates a therapeutic effect of this medication?

  • A. Erythrocyte count
  • B. Neutrophil count
  • C. Lymphocyte count
  • D. Thrombocyte count
Correct Answer: B

Rationale: Filgrastim is a medication used to stimulate the production of neutrophils in patients with neutropenia. Neutrophils are a type of white blood cell that plays a crucial role in fighting off infections. Therefore, an increase in neutrophil count would indicate a therapeutic effect of filgrastim. The other options, such as erythrocyte count (red blood cells), lymphocyte count, and thrombocyte count (platelets), are not directly affected by filgrastim and would not indicate a therapeutic effect of this medication.

A nurse is preparing to administer amoxicillin 250 mg liquid suspension PO every 8 hr to an older adult client. The amount available is amoxicillin 50 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number)

  • A. 5 mL
  • B. 6 mL
  • C. 4 mL
  • D. 7 mL
Correct Answer: A

Rationale: To calculate the amount of amoxicillin in mL needed per dose, we can use the formula: 50 mg/mL = 250 mg / X mL. Cross multiply to solve for X: 50X = 250. Divide both sides by 50 to find X, which equals 5 mL per dose. Therefore, the nurse should administer 5 mL of amoxicillin per dose. Choice B, 6 mL, is incorrect as it does not match the calculated result. Choice C, 4 mL, is incorrect as it is too low based on the calculation. Choice D, 7 mL, is incorrect as it is too high based on the calculation.

A nurse is caring for a client who has been taking isoniazid and rifampin for 3 weeks for the treatment of active pulmonary tuberculosis (TB). The client reports his urine is an orange color. Which of the following statements should the nurse make?

  • A. Stop taking the isoniazid for 3 days and the discoloration should go away.
  • B. Rifampin can turn body fluids orange.
  • C. I'll make an appointment for you to see the provider this afternoon.
  • D. Isoniazid can cause bladder irritation.
Correct Answer: B

Rationale: The correct answer is B: 'Rifampin can turn body fluids orange.' Rifampin is known to cause orange discoloration of body fluids, including urine. This side effect is harmless and does not indicate a need to stop the medication. Choice A is incorrect because stopping isoniazid will not resolve the orange urine discoloration caused by rifampin. Choice C is unnecessary at this point since the orange urine is a known side effect of rifampin and does not require an urgent provider visit. Choice D is incorrect because bladder irritation is not typically associated with isoniazid.

A nurse is administering subcutaneous heparin to a client who is at risk for deep vein thrombosis. Which of the following actions should the nurse take?

  • A. Administer the medication into the client's abdomen.
  • B. Inject the medication into a muscle.
  • C. Massage the site after administering the medication.
  • D. Use a 22-gauge needle to administer the medication.
Correct Answer: A

Rationale: Heparin is best absorbed and less likely to cause hematomas when administered into subcutaneous tissue, specifically the abdomen, which is a common site for subcutaneous injections. Injecting heparin into a muscle (Choice B) is incorrect as it should be administered subcutaneously. Massaging the site after administering the medication (Choice C) is contraindicated as it can cause tissue damage or bruising. Using a 22-gauge needle (Choice D) is not recommended for subcutaneous injections of heparin; a smaller needle size such as 25-26 gauge is preferred for subcutaneous administration.

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