ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT FORM B – COMPLETE QUESTIONS WITH VERIFIED ANSWERS

ATI CAPSTONE PROCTORED COMPREHENSIVE ASSESSMENT FORM B – COMPLETE QUESTIONS WITH VERIFIED ANSWERS 1. A nurse is assessing a client who received 2 units of packed RBCs 48 hours ago. Which of the following findings should indicate to the nurse that the therapy has been effective? A. Client reports decreased fatigue B. Hemoglobin 14.9 g/dL C. Client reports increased thirst D. Blood pressure 110/70 mmHg Correct Answer: B. Hemoglobin 14.9 g/dL Rationale: Packed RBCs are administered to clients who have a decreased level of hemoglobin or hematocrit. A hemoglobin level of 14.9 g/dL is within normal range for adult females (12-16 g/dL) and adult males (14-18 g/dL), indicating the therapy has been effective. While decreased fatigue may be a subjective sign of improvement, objective laboratory values are the most reliable indicators of treatment effectiveness. ________________________________________ 2. A nurse is caring for a client who has a new prescription for spironolactone. Which of the following laboratory values should the nurse monitor closely? A. Serum sodium B. Serum potassium C. Serum calcium D. Serum magnesium Correct Answer: B. Serum potassium Rationale: Spironolactone is a potassium-sparing diuretic that can cause hyperkalemia by reducing potassium excretion in the distal tubules. The nurse should monitor serum potassium levels closely and report levels above 5.0 mEq/L to the provider. Clients should be advised to avoid potassium-rich foods and salt substitutes containing potassium. ________________________________________ 3. A nurse is teaching a client who has a new prescription for phenytoin. Which of the following information should the nurse include? A. Take the medication with milk to reduce GI upset B. Monitor for gum overgrowth and perform good oral hygiene C. The medication can be crushed if you have difficulty swallowing D. Stop taking the medication if you experience drowsiness Correct Answer: B. Monitor for gum overgrowth and perform good oral hygiene Rationale: Phenytoin is an anticonvulsant medication that commonly causes gingival hyperplasia (gum overgrowth). Clients should be instructed to perform frequent oral hygiene, including brushing and flossing, and to visit the dentist regularly. Drowsiness is a common side effect and the medication should not be stopped abruptly, as this can precipitate seizures. ________________________________________ 4. A nurse is assessing a client who has major depressive disorder and is taking amitriptyline. Which of the following findings should the nurse report to the provider? A. Dry mouth B. Blurred vision C. Urinary retention D. Heart rate 110/min Correct Answer: D. Heart rate 110/min Rationale: Amitriptyline is a tricyclic antidepressant that can cause tachycardia, arrhythmias, and other cardiac effects. A heart rate of 110/min is above the normal range and should be reported to the provider. Dry mouth, blurred vision, and urinary retention are common anticholinergic side effects of amitriptyline that should be monitored but do not require immediate provider notification unless severe. ________________________________________ 5. A nurse is preparing to administer timolol eye drops. Which of the following actions should the nurse take? A. Apply pressure to the nasolacrimal duct after instillation B. Shake the medication vigorously before use C. Have the client look down during instillation D. Administer the drops directly onto the cornea Correct Answer: A. Apply pressure to the nasolacrimal duct after instillation Rationale: Applying pressure to the nasolacrimal duct (occlusion) for 1-2 minutes after instilling eye drops reduces systemic absorption by preventing the medication from draining through the tear duct into the nasal cavity. This is particularly important for timolol, a beta-blocker that can have systemic cardiovascular effects if absorbed. ________________________________________ 6. A nurse is caring for a client who is receiving total parenteral nutrition (TPN) via a central venous catheter. Which of the following complications should the nurse monitor for? A. Hypoglycemia B. Hyperkalemia C. Hypercalcemia D. Hypermagnesemia Correct Answer: A. Hypoglycemia Rationale: Clients receiving TPN are at risk for hypoglycemia if the infusion is stopped abruptly, as the high glucose concentration in TPN suppresses endogenous insulin production. When TPN is discontinued, the nurse should taper the rate gradually to prevent rebound hypoglycemia. Blood glucose levels should be monitored closely. ________________________________________ 7. A nurse is caring for a client who has a chest tube connected to a water-seal drainage system. Which of the following findings should the nurse report to the provider? A. Continuous bubbling in the water-seal chamber B. Intermittent bubbling in the water-seal chamber C. Tidaling in the water-seal chamber D. Drainage of 50 mL in the first hour Correct Answer: A. Continuous bubbling in the water-seal chamber