NUR 2989 - ATI QUIZ CAPSTONE PROCTORED MODULE 3
QUESTIONS AND ANSWERS WITH RATIONALE
QUESTION 1
A nurse is developing a plan of care for an older adult who is at risk for
falls. Which of the following actions should the nurse plan to include in
the plan? (SELECT ALL THAT APPLY)
A. Lock beds and wheelchairs when not providing care
B. Administer a sedative at bedtime
C. Provide information about home safety checks
D. Teach balance and strengthening exercises
E. Place the bedside table within the client's reach
VERIFIED ANSWER: A, C, D, E
Rationale:
• A. Lock beds and wheelchairs when not providing
care: CORRECT. Locking wheels prevents equipment from moving
unexpectedly, reducing fall risk.
• B. Administer a sedative at bedtime: INCORRECT. Sedatives can
cause confusion, orthostatic hypotension, and morning hangover
effects, actually increasing fall risk.
• C. Provide information about home safety checks: CORRECT.
Environmental modifications (removing rugs, improving lighting)
are essential fall prevention strategies.
, • D. Teach balance and strengthening exercises: CORRECT.
Exercise improves muscle strength, coordination, and balance,
reducing fall risk.
• E. Place the bedside table within the client's reach: CORRECT.
Keeping essential items within reach prevents dangerous
reaching and overbalancing.
QUESTION 2
A nurse is providing teaching to a client who has schizophrenia about
thioridazine. Which of the following instructions should the nurse
include in the teaching?
A. Report any sign of infection to the provider immediately
B. Expect your blood pressure to increase
C. Easy bruising may occur while taking this medication
D. Muscle rigidity is an expected adverse effect during the first few
days of therapy
VERIFIED ANSWER: A
Rationale: Thioridazine is an antipsychotic medication that can cause
agranulocytosis (severe lowering of white blood cells). Clients should
be instructed to report any signs of infection (fever, sore throat)
immediately as this may indicate a dangerous drop in WBC count.
Thioridazine typically causes hypotension, not hypertension. Easy
bruising is not a common adverse effect. Muscle rigidity is not an
expected effect and may indicate extrapyramidal symptoms that
require medical attention.
,QUESTION 3
A nurse is teaching a client who has a new prescription for amoxicillin
clavulanate to treat pharyngitis. Which of the following statements by
the client indicates an understanding of the teaching?
A. I will double my dose if I miss one
B. I should take this medication on an empty stomach between meals
C. I will take medication until my sore throat goes away
D. I will stop taking this medication if I develop itching
VERIFIED ANSWER: D
Rationale: Itching may indicate an allergic reaction to the antibiotic.
The client should stop taking the medication and notify the provider
immediately. Doses should never be doubled. Amoxicillin clavulanate
should be taken with food to reduce gastrointestinal upset. Antibiotics
must be taken for the full prescribed course, not just until symptoms
resolve, to prevent antibiotic resistance and recurrence of infection.
QUESTION 4
A nurse is preparing to administer medications to four clients. The
nurse should administer medications to which of the following clients
first?
A. A client who has pneumonia, a WBC count of 11,500/mm³, and is
prescribed piperacillin
B. A client who has renal failure, a serum potassium of 5.8 mEq/L, and
, is prescribed sodium polystyrene sulfonate
C. A client who is post coronary artery bypass graft (CABG), has total
cholesterol of 318 mg/dL, and is prescribed atorvastatin
D. A client who has anemia, hemoglobin of 11 g/dL, and is prescribed
epoetin alfa
VERIFIED ANSWER: B
Rationale: A serum potassium of 5.8 mEq/L indicates hyperkalemia,
which can lead to life-threatening cardiac dysrhythmias. Sodium
polystyrene sulfonate (Kayexalate) is administered to lower potassium
levels and should be given immediately. The other clients have
conditions that are serious but not immediately life-threatening. The
WBC count of 11,500/mm³ with pneumonia is expected. Cholesterol of
318 mg/dL post-CABG requires treatment but is not emergent.
Hemoglobin of 11 g/dL with anemia requires treatment but is not acute.
QUESTION 5
A nurse caring for a client who is vomiting. Which of the following
actions should the nurse take first?
A. Administer an antiemetic to the client
B. Notify housekeeping
C. Prevent the client from aspirating
D. Providing the client with an emesis basin
VERIFIED ANSWER: C
QUESTIONS AND ANSWERS WITH RATIONALE
QUESTION 1
A nurse is developing a plan of care for an older adult who is at risk for
falls. Which of the following actions should the nurse plan to include in
the plan? (SELECT ALL THAT APPLY)
A. Lock beds and wheelchairs when not providing care
B. Administer a sedative at bedtime
C. Provide information about home safety checks
D. Teach balance and strengthening exercises
E. Place the bedside table within the client's reach
VERIFIED ANSWER: A, C, D, E
Rationale:
• A. Lock beds and wheelchairs when not providing
care: CORRECT. Locking wheels prevents equipment from moving
unexpectedly, reducing fall risk.
• B. Administer a sedative at bedtime: INCORRECT. Sedatives can
cause confusion, orthostatic hypotension, and morning hangover
effects, actually increasing fall risk.
• C. Provide information about home safety checks: CORRECT.
Environmental modifications (removing rugs, improving lighting)
are essential fall prevention strategies.
, • D. Teach balance and strengthening exercises: CORRECT.
Exercise improves muscle strength, coordination, and balance,
reducing fall risk.
• E. Place the bedside table within the client's reach: CORRECT.
Keeping essential items within reach prevents dangerous
reaching and overbalancing.
QUESTION 2
A nurse is providing teaching to a client who has schizophrenia about
thioridazine. Which of the following instructions should the nurse
include in the teaching?
A. Report any sign of infection to the provider immediately
B. Expect your blood pressure to increase
C. Easy bruising may occur while taking this medication
D. Muscle rigidity is an expected adverse effect during the first few
days of therapy
VERIFIED ANSWER: A
Rationale: Thioridazine is an antipsychotic medication that can cause
agranulocytosis (severe lowering of white blood cells). Clients should
be instructed to report any signs of infection (fever, sore throat)
immediately as this may indicate a dangerous drop in WBC count.
Thioridazine typically causes hypotension, not hypertension. Easy
bruising is not a common adverse effect. Muscle rigidity is not an
expected effect and may indicate extrapyramidal symptoms that
require medical attention.
,QUESTION 3
A nurse is teaching a client who has a new prescription for amoxicillin
clavulanate to treat pharyngitis. Which of the following statements by
the client indicates an understanding of the teaching?
A. I will double my dose if I miss one
B. I should take this medication on an empty stomach between meals
C. I will take medication until my sore throat goes away
D. I will stop taking this medication if I develop itching
VERIFIED ANSWER: D
Rationale: Itching may indicate an allergic reaction to the antibiotic.
The client should stop taking the medication and notify the provider
immediately. Doses should never be doubled. Amoxicillin clavulanate
should be taken with food to reduce gastrointestinal upset. Antibiotics
must be taken for the full prescribed course, not just until symptoms
resolve, to prevent antibiotic resistance and recurrence of infection.
QUESTION 4
A nurse is preparing to administer medications to four clients. The
nurse should administer medications to which of the following clients
first?
A. A client who has pneumonia, a WBC count of 11,500/mm³, and is
prescribed piperacillin
B. A client who has renal failure, a serum potassium of 5.8 mEq/L, and
, is prescribed sodium polystyrene sulfonate
C. A client who is post coronary artery bypass graft (CABG), has total
cholesterol of 318 mg/dL, and is prescribed atorvastatin
D. A client who has anemia, hemoglobin of 11 g/dL, and is prescribed
epoetin alfa
VERIFIED ANSWER: B
Rationale: A serum potassium of 5.8 mEq/L indicates hyperkalemia,
which can lead to life-threatening cardiac dysrhythmias. Sodium
polystyrene sulfonate (Kayexalate) is administered to lower potassium
levels and should be given immediately. The other clients have
conditions that are serious but not immediately life-threatening. The
WBC count of 11,500/mm³ with pneumonia is expected. Cholesterol of
318 mg/dL post-CABG requires treatment but is not emergent.
Hemoglobin of 11 g/dL with anemia requires treatment but is not acute.
QUESTION 5
A nurse caring for a client who is vomiting. Which of the following
actions should the nurse take first?
A. Administer an antiemetic to the client
B. Notify housekeeping
C. Prevent the client from aspirating
D. Providing the client with an emesis basin
VERIFIED ANSWER: C
