ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A charge nurse is planning care for a group of patients on a med-surg unit. What task should the nurse delegate to an assistive personnel?
- A. Measure hourly urinary output for the postoperative patient.
- B. Administer medications to stable patients.
- C. Reinforce patient education.
- D. Initiate a care plan for a new patient.
Correct answer: A
Rationale: The correct answer is A because assistive personnel can be assigned to measure and document urinary output, a routine task within their scope of practice. Administering medications (choice B) requires a higher level of training and should be done by licensed nurses. Reinforcing patient education (choice C) involves providing information and ensuring patient understanding, which is typically done by licensed healthcare providers. Initiating a care plan (choice D) involves critical thinking and assessment skills, which are beyond the scope of practice for assistive personnel.
2. What is the most appropriate nursing diagnosis for a patient with agoraphobia who reports not having left their house in months?
- A. Social isolation
- B. Ineffective coping
- C. Risk for injury
- D. Impaired social interaction
Correct answer: A
Rationale: The nursing diagnosis 'Social isolation' is most appropriate for a patient with agoraphobia who has not left their house in months. Agoraphobia often leads to the avoidance of situations or places perceived as unsafe, resulting in social isolation. This diagnosis reflects the patient's limited social interactions and confinement to the home environment, which can impact their overall well-being and mental health. The other options are not as relevant in this scenario: 'Ineffective coping' does not directly address the social withdrawal aspect, 'Risk for injury' is not the primary concern presented, and 'Impaired social interaction' does not capture the extent of isolation described.
3. Before drying off the newborn after birth, which assessment finding should the healthcare professional document to ensure an accurate gestational rating on the Ballard gestational assessment tool?
- A. Amount and area of vernix coverage
- B. Creases on the sole
- C. Size of the areola
- D. Body surface temperature
Correct answer: A
Rationale: To ensure an accurate gestational rating on the Ballard gestational assessment tool, healthcare professionals should document the amount and area of vernix coverage before drying the newborn. Drying the baby after birth could disturb the vernix, potentially affecting the gestational age assessment. Assessing and documenting the vernix coverage beforehand enables a more precise evaluation using the Ballard gestational assessment tool. Choices B, C, and D are incorrect as they are not directly related to gestational rating on the Ballard assessment tool.
4. A client with hypertension is receiving dietary education from a nurse. Which recommendation should the nurse include?
- A. Increase your intake of saturated fats.
- B. Limit your sodium intake to less than 2 grams per day.
- C. Avoid foods high in potassium.
- D. Consume at least three alcoholic beverages daily.
Correct answer: B
Rationale: The correct recommendation for a client with hypertension is to limit sodium intake to less than 2 grams per day. High sodium intake can worsen hypertension by increasing blood pressure. Choices A, C, and D are incorrect. Increasing saturated fats (Choice A) can be detrimental to heart health and exacerbate hypertension. Avoiding foods high in potassium (Choice C) is not recommended as potassium-rich foods can actually be beneficial for managing blood pressure. Consuming three alcoholic beverages daily (Choice D) can also have a negative impact on blood pressure and overall health.
5. A 4-year-old boy ingested an unknown quantity of drain cleaner. He is alert, has a patent airway, and has adequate breathing. You should:
- A. administer 1 g/kg of activated charcoal.
- B. give 15 mL of ipecac and contact medical control.
- C. contact poison control and give him oxygen.
- D. give oxygen and perform a head-to-toe exam.
Correct answer: C
Rationale: When a child ingests a harmful substance like drain cleaner and remains alert with a patent airway and adequate breathing, the initial steps involve contacting poison control to guide further management. In this scenario, providing oxygen to support respiratory function is essential until definitive care is established. Activated charcoal and ipecac are not recommended in the management of ingested caustic substances like drain cleaner. Performing a head-to-toe exam can wait until the child's immediate respiratory needs are addressed and the poison control center has provided guidance on further management.
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