LPN LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate via IV infusion. Which of the following findings indicates magnesium toxicity?
- A. Blood glucose of 150 mg/dL
- B. Urine output of 20 mL/hour
- C. Systolic blood pressure of 140 mm Hg
- D. BUN 20 mg/dL
Correct answer: B
Rationale: The correct answer is B. A urine output of 20 mL/hour is a sign of magnesium toxicity because decreased urine output can lead to accumulation of magnesium. Choices A, C, and D are not indicators of magnesium toxicity. Elevated blood glucose, high systolic blood pressure, and normal BUN levels do not specifically point towards magnesium toxicity.
2. A nurse is planning care for a client with a sealed radiation implant. Which intervention should the nurse implement?
- A. Remove dirty linens after double-bagging them
- B. Wear a dosimeter badge in the client’s room
- C. Limit visitors to 1 hour per day
- D. Ensure family remains 3 feet away from the client
Correct answer: B
Rationale: The nurse should wear a dosimeter badge to monitor radiation exposure when caring for a client with a sealed radiation implant.
3. A client is being taught how to use a PCA pump postoperatively. Which statement indicates understanding?
- A. I should wait until the pain is severe before using the PCA pump.
- B. My family can press the button for me when I'm asleep.
- C. I will press the button when I start to feel pain.
- D. I will only press the button once per hour.
Correct answer: C
Rationale: The correct answer is C because the client should press the PCA pump button when they start to feel pain. This approach helps maintain pain control effectively. Choice A is incorrect because waiting for the pain to become severe before using the PCA pump can lead to inadequate pain management. Choice B is incorrect because only the client should operate the PCA pump to ensure the correct dosage is administered. Choice D is incorrect because the client should press the button as needed when experiencing pain, rather than limiting its use to once per hour.
4. When caring for a client with a sealed radiation implant, which action should be included in the plan of care?
- A. Remove dirty linens after double bagging them
- B. Wear a dosimeter film badge while in the client’s room
- C. Limit visitors to 1 hour per day
- D. Ensure family members remain at least 3 feet from the client
Correct answer: B
Rationale: The correct answer is to wear a dosimeter film badge while in the client's room. This is crucial for monitoring radiation exposure levels when caring for a client with a sealed radiation implant. Option A is incorrect as removing dirty linens after double bagging them is not directly related to radiation safety. Option C is incorrect as there is no specific guideline to limit visitors to 1 hour per day for clients with sealed radiation implants. Option D is incorrect as the distance of family members from the client is not a primary safety measure when dealing with sealed radiation implants.
5. A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?
- A. I will make sure my medications are enteric-coated.
- B. My stoma will drain liquid continuously.
- C. I will change my pouch system every two weeks.
- D. My stoma size will stay the same after it heals.
Correct answer: B
Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.
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