ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A client diagnosed with pneumonia is receiving oxygen therapy at 4 L/min via nasal cannula. Which of the following interventions is most important?
- A. Encourage fluid intake.
- B. Monitor oxygen saturation levels.
- C. Change the oxygen tubing daily.
- D. Assist with frequent position changes.
Correct answer: B
Rationale: Monitoring oxygen saturation levels is the most important intervention in this scenario. It ensures that the client is receiving adequate oxygenation, which is crucial for a client with pneumonia. By monitoring saturation levels, the nurse can promptly identify any oxygenation issues and adjust the oxygen delivery if necessary. Encouraging fluid intake, changing oxygen tubing daily, and assisting with frequent position changes are also important aspects of care for a client with pneumonia, but they are not as critical as monitoring oxygen saturation levels in ensuring immediate respiratory support.
2. A client who is 32 weeks pregnant and has a diagnosis of placenta previa is receiving teaching from a nurse. Which of the following instructions should the nurse include?
- A. Limit physical activity
- B. Monitor fetal movements daily
- C. Call the healthcare provider if contractions begin
- D. All of the above
Correct answer: D
Rationale: Clients diagnosed with placenta previa are at an increased risk of bleeding and preterm labor. Therefore, it is essential for them to limit physical activity to prevent complications. Monitoring fetal movements daily helps in assessing the well-being of the fetus. Additionally, notifying the healthcare provider if contractions begin is crucial as it could be a sign of preterm labor. Therefore, all of the instructions (limiting physical activity, monitoring fetal movements, and calling the healthcare provider if contractions begin) are necessary for managing placenta previa effectively. Choices A, B, and C are all correct instructions for a client with placenta previa.
3. A client has been prescribed amlodipine for hypertension. Which of the following adverse effects should the nurse instruct the client to report?
- A. Dry cough
- B. Dizziness
- C. Rash
- D. Headache
Correct answer: B
Rationale: The correct answer is B: 'Dizziness.' Amlodipine, a calcium channel blocker used for hypertension, can cause dizziness due to its blood pressure-lowering effects. It is crucial for clients to report dizziness to their healthcare provider as it may indicate hypotension. Dry cough (choice A) is more commonly associated with ACE inhibitors, rash (choice C) may be seen in allergic reactions, and headache (choice D) is a less common side effect of amlodipine.
4. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?
- A. Diaphoresis
- B. Polyuria
- C. Abdominal pain
- D. Thirst
Correct answer: A
Rationale: The correct answer is A: Diaphoresis. Diaphoresis (sweating) is a classic symptom of hypoglycemia, along with shakiness, confusion, and irritability. These signs help indicate low blood sugar levels. Choices B, C, and D are incorrect. Polyuria (excessive urination), abdominal pain, and thirst are not typical symptoms associated with hypoglycemia. It is crucial for clients with type 1 diabetes mellitus to recognize the early signs of hypoglycemia to take prompt corrective action.
5. A client who has osteoporosis is being discharged with a new prescription for alendronate. Which of the following instructions should the nurse provide?
- A. Take the medication at bedtime.
- B. Take the medication with a full glass of water.
- C. Take the medication with food.
- D. Lie down for 30 minutes after taking the medication.
Correct answer: B
Rationale: The correct answer is to take the medication with a full glass of water. Alendronate should be taken with a full glass of water to prevent esophageal irritation. Additionally, the client should remain upright for 30 minutes after taking it to prevent potential adverse effects. Choice A is incorrect because alendronate should not be taken at bedtime, but rather in the morning on an empty stomach. Choice C is incorrect because alendronate should be taken on an empty stomach, not with food. Choice D is incorrect because the client should remain upright, not lie down, for 30 minutes after taking the medication.
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