A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client has a productive cough and is started on airborne precautions. Which of the following interventions should the nurse implement?

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PN ATI Capstone Proctored Comprehensive Assessment Form B Questions

Question 1 of 5

A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client has a productive cough and is started on airborne precautions. Which of the following interventions should the nurse implement?

Correct Answer: A

Rationale: The correct answer is to wear an N95 respirator mask when caring for the client with TB. This is crucial to prevent the nurse from inhaling the airborne particles that spread the infection. Choice B is incorrect because placing the client in a semi-private room does not address the protection of the nurse. Choice C is incorrect as having the client wear a surgical mask during meals is not sufficient to protect the nurse during all interactions. Choice D is incorrect as using a negative pressure air filtration system is more applicable to airborne infection isolation rooms in healthcare settings and not a standard intervention for nurses caring for a single client with TB.

Question 2 of 5

A nurse is caring for a client who is postoperative following a thyroidectomy. The client reports tingling in the fingers and around the mouth. The nurse should anticipate which of the following interventions?

Correct Answer: A

Rationale: Tingling in the fingers and around the mouth is a sign of hypocalcemia, which can occur after thyroid surgery due to accidental damage to the parathyroid glands. Hypocalcemia is common after thyroidectomy due to potential parathyroid damage. Calcium gluconate is the appropriate intervention to treat hypocalcemia. Providing a high-protein diet or administering levothyroxine are not indicated for hypocalcemia. Applying a warm compress to the client's neck would not address the underlying issue of hypocalcemia.

Question 3 of 5

A nurse is assessing a client who has a history of atrial fibrillation and is receiving warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the warfarin?

Correct Answer: B

Rationale: The correct answer is B: International normalized ratio (INR). The INR is used to monitor the effectiveness of warfarin therapy. A higher INR indicates a longer time it takes for the blood to clot, which is desirable in patients receiving warfarin to prevent blood clots. Platelet count (Choice A) assesses the number of platelets in the blood and is not directly related to warfarin therapy. Bleeding time (Choice C) evaluates the time it takes for a person to stop bleeding after a standardized wound, but it is not specific to monitoring warfarin effectiveness. Partial thromboplastin time (PTT) (Choice D) is more commonly used to monitor heparin therapy, not warfarin.

Question 4 of 5

A client with chronic kidney disease is about to start hemodialysis. Which of the following instructions should the nurse include?

Correct Answer: B

Rationale: The correct answer is to instruct the client to reduce potassium intake. Clients with chronic kidney disease should limit potassium intake to prevent hyperkalemia, as the kidneys may struggle to remove excess potassium. Increasing protein intake between dialysis sessions (Choice A) is not recommended as it can increase urea production, adding to the workload of the kidneys. Avoiding iron supplements (Choice C) is not necessary unless iron levels are high. Expecting weight gain after each dialysis session (Choice D) is incorrect as patients typically experience weight loss due to fluid removal during dialysis.

Question 5 of 5

While caring for a client receiving oxytocin for labor augmentation, the nurse notes contractions occurring every 45 seconds and lasting 90 seconds. What should the nurse do?

Correct Answer: A

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. The client is experiencing uterine hyperstimulation, which can lead to fetal distress and complications. By stopping the oxytocin, the nurse can help regulate contractions and prevent harm to the fetus. Increasing the oxytocin infusion would exacerbate the issue by further intensifying contractions. Applying an internal fetal monitor may be necessary for closer monitoring but is not the immediate action required. Administering an analgesic is not appropriate in this scenario as the primary concern is addressing the uterine hyperstimulation caused by oxytocin.

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