A nurse is preparing to administer total parenteral nutrition (TPN) to a client. Which of the following findings indicates a need to obtain a new bag of TPN before administering?

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PN ATI Capstone Proctored Comprehensive Assessment 2020 B Questions

Question 1 of 5

A nurse is preparing to administer total parenteral nutrition (TPN) to a client. Which of the following findings indicates a need to obtain a new bag of TPN before administering?

Correct Answer: A

Rationale: A TPN solution with an oily appearance and a layer of fat on top indicates that the solution is 'cracked' and should not be used as it may have separated or deteriorated. This finding suggests a need to obtain a new bag of TPN before administering. Options B, C, and D are normal aspects of TPN administration. Option B confirms the presence of essential components in the TPN solution, option C provides information about the preparation time, and option D ensures proper identification and matching of the TPN with the correct client.

Question 2 of 5

A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a catheter occlusion?

Correct Answer: B

Rationale: The correct answer is B: Bladder distention. Bladder distention indicates that the bladder is full and there is impaired elimination, which could be caused by catheter occlusion. Pain during urination (choice A) is not typically associated with catheter occlusion but may indicate a urinary tract infection. Cloudy urine (choice C) can be a sign of infection but is not specific to catheter occlusion. Blood in the catheter tube (choice D) may indicate trauma during catheter insertion but is not a typical finding in catheter occlusion.

Question 3 of 5

A nurse is caring for an older adult who has a non-palpable skin lesion that is less than 0.5 cm in diameter. Which term should the nurse use to document this finding?

Correct Answer: B

Rationale: The correct answer is B: Macule. A macule is a non-palpable skin lesion smaller than 1 cm in diameter. In this case, the skin lesion described is less than 0.5 cm, making it consistent with a macule. Vesicle (choice A) is a small blister filled with clear fluid, papule (choice C) is a solid, raised skin lesion less than 0.5 cm in diameter, and nodule (choice D) is a palpable, solid lesion larger than 0.5 cm in diameter. Therefore, choices A, C, and D describe skin lesions that do not match the characteristics of the lesion presented in the question.

Question 4 of 5

A nurse is in an acute care facility, caring for a client who is postop following abdominal surgery. Which behavior should the nurse identify as increasing the client's risk for constipation?

Correct Answer: B

Rationale: The correct answer is B: 'Suppression of the urge to defecate.' Suppressing the urge to defecate can lead to constipation, especially in postoperative clients. It is essential to encourage clients to respond to the urge to defecate to prevent constipation. Increased fiber intake (Choice A) is beneficial for preventing constipation. Ambulation (Choice C) helps promote bowel motility and can reduce the risk of constipation. Daily laxative use (Choice D) may contribute to laxative dependence but is not the behavior most directly associated with increasing the risk of constipation in this scenario.

Question 5 of 5

A nurse is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates an understanding of the teaching?

Correct Answer: B

Rationale: Choice B is the correct answer because having a living will is a legal document that outlines a client's wishes when they are unable to make decisions, indicating a good understanding of advance directives. Choice A is incorrect because it doesn't mention a specific document like a living will. Choice C is incorrect because advance directives, like a living will, can be legally binding. Choice D is incorrect because planning for advance directives should ideally be done before a person becomes critically ill.

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