A nurse is planning to delegate client assignments to the assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

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PN ATI Capstone Proctored Comprehensive Assessment A Questions

Question 1 of 5

A nurse is planning to delegate client assignments to the assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?

Correct Answer: B

Rationale: The correct answer is B: Collect a urine sample. Delegating this task to assistive personnel is appropriate as it falls within their scope of practice. Tasks like adjusting the flow rate of oxygen tanks, measuring pain levels, and monitoring blood glucose levels require clinical judgment and should be performed by a nurse. It is important for nurses to delegate tasks that align with the competencies of assistive personnel to ensure safe and effective patient care.

Question 2 of 5

A nurse is providing discharge instructions about breast engorgement to a client who has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction?

Correct Answer: C

Rationale: The correct answer is C. Manually expressing breast milk will stimulate more milk production, which contradicts the goal of reducing milk supply in clients who choose not to breastfeed. Choices A, B, and D are correct statements that can help relieve breast engorgement without promoting further milk production.

Question 3 of 5

A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?

Correct Answer: B

Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.

Question 4 of 5

A nurse is completing an assessment of a newborn who is 2 hours old. Which of the following findings is indicative of cold stress?

Correct Answer: B

Rationale: Jitteriness of the hands is a classic sign of cold stress in newborns, indicating that the infant is having difficulty maintaining a stable body temperature. Cold stress can lead to hypoglycemia and increased oxygen consumption. The other options (A, C, and D) are not directly associated with cold stress in newborns. A respiratory rate of 60 per minute may be within the normal range for a newborn. Diaphoresis (excessive sweating) and bounding peripheral pulses are not specific signs of cold stress in newborns.

Question 5 of 5

A client wearing an arm cast reports numb fingers. Which of the following actions should the nurse take first?

Correct Answer: C

Rationale: The correct answer is to check the client's circulation. Numbness in the fingers may indicate compromised circulation or nerve damage. By assessing the circulation first, the nurse can ensure that the cast is not too tight, which could be cutting off blood flow. Option A is incorrect because placing the arm in a dependent position may worsen circulation issues. Option B is incorrect as administering pain medication does not address the underlying cause of numbness. Option D is incorrect as applying a warm compress could mask circulation issues and is not the priority in this situation.

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