ATI RN
RN ATI Capstone Proctored Comprehensive Assessment Form B Questions
Extract:
Question 1 of 5
A nurse is planning care for a client who is experiencing benzodiazepine toxicity. The nurse should plan to administer which of the following medications?
Correct Answer: Flumazenil reverses benzodiazepine toxicity. Atropine, naloxone, and charcoal are for other conditions.
Rationale: The correct answer is B: Flumazenil. Flumazenil is a benzodiazepine receptor antagonist that reverses the effects of benzodiazepine toxicity by competitively inhibiting the binding of benzodiazepines at the receptor sites. Atropine is used for treating bradycardia and organophosphate poisoning. Naloxone is used for opioid overdose reversal. Activated charcoal is used for poisoning by ingestion to absorb toxins.
Therefore, the correct choice is Flumazenil as it specifically targets benzodiazepine toxicity.
Question 2 of 5
A nurse is caring for a client who has a new prescription for spironolactone and reports that they forgot to tell the provider that they take over-the-counter supplements. The nurse should instruct the client to avoid which of the following supplements?
Correct Answer: Spironolactone is potassium-sparing; potassium supplements can cause hyperkalemia. Iron, calcium, and magnesium are not contraindicated.
Rationale: The correct answer is D: Potassium. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium.
Therefore, taking additional potassium supplements along with spironolactone can lead to excessive levels of potassium in the blood, known as hyperkalemia. Hyperkalemia can be dangerous and lead to serious health complications such as heart rhythm abnormalities. Iron, calcium, and magnesium supplements do not interact negatively with spironolactone. It is important for the client to avoid potassium supplements while taking spironolactone to prevent the risk of hyperkalemia.
Question 3 of 5
A nurse is reviewing the medical record of a client who has a prescription for misoprostol for induction of labor. Which of the following findings is a contraindication for administration of this medication?
Correct Answer: Transverse fetal lie contraindicates misoprostol due to risks like cord prolapse. Other conditions may warrant its use.
Rationale: The correct answer is B: Transverse fetal lie. Misoprostol is contraindicated in cases of transverse fetal lie due to the risk of cord prolapse, which can lead to serious complications during labor. In transverse lie, the baby is positioned sideways in the uterus, increasing the likelihood of the umbilical cord slipping down before the baby, cutting off their oxygen supply. This situation requires immediate intervention, usually through a cesarean section.
Preeclampsia (choice
A), post-term pregnancy (choice
C), and intrauterine growth restriction (choice
D) are not contraindications for misoprostol administration. In fact, misoprostol may be used in these conditions to induce labor when necessary.
In summary, the presence of a transverse fetal lie poses a significant risk of cord prolapse and subsequent complications during labor, making it a contraindication for the use of misoprostol in this scenario.
Question 4 of 5
A nurse is developing a plan of care for a child who is in skeletal traction following a femur fracture. Which of the following actions should the nurse include in the plan?
Correct Answer: Pin site care education prevents infection. Lifting weights disrupts traction, and pain and neurovascular checks need more frequent monitoring.
Rationale: The correct answer is D: Educate the child's guardians about pin site care prior to discharge. Educating the guardians about pin site care is crucial in preventing infection, which is a common complication of skeletal traction. By teaching proper cleaning techniques and signs of infection, the guardians can help maintain the child's health during the recovery process.
A: Lifting the traction weights when repositioning the child in bed can disrupt the traction and should be avoided to prevent complications.
B: Having the child rate their pain every 8 hours is important, but it should be done more frequently to ensure timely pain management.
C: Monitoring the neurovascular status of the child's lower extremities every 12 hours is not frequent enough as changes can occur quickly and require more frequent assessment.
In summary, educating the guardians about pin site care is essential for preventing infection, while the other actions either disrupt traction or require more frequent monitoring for optimal care.
Question 5 of 5
A nurse is caring for a client who is taking disulfiram for alcohol use disorder and reports ingestion of alcohol. For which of the following adverse effects should the nurse monitor?
Correct Answer: Headache is a common symptom of the disulfiram-alcohol reaction. Hypertension, insomnia, and tinnitus are less typical.
Rationale: The correct answer is B: Headache. Disulfiram causes an unpleasant reaction when alcohol is consumed, leading to symptoms like headache, nausea, vomiting, and flushing. Headache is a common side effect due to the inhibition of aldehyde dehydrogenase, causing acetaldehyde buildup. Hypertension is not a typical reaction to disulfiram-alcohol interaction. Insomnia is not a direct effect but may occur due to discomfort. Tinnitus is also not a common symptom associated with disulfiram use. Monitoring for headache is crucial to assess the effectiveness of disulfiram therapy and encourage abstinence from alcohol.