ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A client has been prescribed lithium for bipolar disorder. Which of the following should the nurse teach the client to monitor for signs of toxicity?
- A. Nausea and vomiting
- B. Increased urination
- C. Tremors
- D. Blurred vision
Correct answer: C
Rationale: The correct answer is C: Tremors. Lithium toxicity can present with symptoms such as tremors, nausea, and blurred vision. Tremors are a common early sign of lithium toxicity and should be monitored closely. While nausea and vomiting can also occur with lithium toxicity, tremors are more specific to lithium toxicity. Increased urination is not typically associated with lithium toxicity, and blurred vision is less common compared to tremors in this context.
2. A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safety hazard?
- A. A client’s wrist restraints tied to the bed rails
- B. A client’s bedside table placed across the foot of the bed
- C. A meal tray left at the bedside from breakfast
- D. A call light extension cord pinned to the bedspread
Correct answer: A
Rationale: The correct answer is A. Tying wrist restraints to the bed rails is a safety hazard because if the bed rails are lowered, the restraints can tighten and cause injury or asphyxiation. Choice B, placing a bedside table across the foot of the bed, may not be ideal for convenience but does not pose a direct safety hazard. Choice C, leaving a meal tray at the bedside from breakfast, is more of an infection control issue than an immediate safety hazard. Choice D, having a call light extension cord pinned to the bedspread, is also not a direct safety hazard unless it poses a risk of entanglement or tripping, which is not indicated in the scenario.
3. A nurse is preparing to administer an intramuscular injection to an adult client. At what angle should the nurse administer the medication using the ventrogluteal site?
- A. 90-degree angle
- B. 60-degree angle
- C. 75-degree angle
- D. 45-degree angle
Correct answer: A
Rationale: The correct answer is A: 90-degree angle. The ventrogluteal site is preferred for intramuscular injections because it is away from major nerves and blood vessels. Administering the injection at a 90-degree angle ensures that the medication reaches deep into the muscle tissue, allowing for proper absorption of the drug. Choice B, 60-degree angle, is incorrect as it is not the recommended angle for the ventrogluteal site. Choice C, 75-degree angle, and Choice D, 45-degree angle, are also incorrect as they are not the appropriate angles for administering an intramuscular injection using the ventrogluteal site.
4. A client with a new diagnosis of hypertension is being taught about lifestyle modifications by a nurse. What dietary change should the nurse recommend?
- A. Increase sodium intake
- B. Limit alcohol consumption
- C. Eat a high-protein diet
- D. Follow a high-fat diet
Correct answer: B
Rationale: The correct answer is B: Limit alcohol consumption. When managing hypertension, it is crucial to reduce alcohol intake as it can raise blood pressure. High alcohol consumption can also interfere with the effectiveness of antihypertensive medications. Choices A, C, and D are incorrect. Increasing sodium intake (Choice A) is not recommended for hypertension as it can lead to fluid retention and elevated blood pressure. Eating a high-protein diet (Choice C) or following a high-fat diet (Choice D) are also not ideal for managing hypertension, as they can have negative impacts on cardiovascular health.
5. A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which client information should the nurse identify as a contributing factor to the decrease in the medication's effectiveness?
- A. Taking the medication with water
- B. Skipping doses of medication
- C. A history of recurring bowel inflammation
- D. Taking anti-inflammatory medication without food
Correct answer: C
Rationale: The correct answer is C. A history of recurring bowel inflammation can impact the absorption and effectiveness of arthritis medication. Bowel inflammation can affect the body's ability to absorb the medication properly, leading to decreased effectiveness. Choices A, B, and D do not directly relate to the decreased effectiveness of the arthritis medication. Taking medication with water, skipping doses, or taking anti-inflammatory medication without food may not be ideal practices but are not directly linked to the decrease in effectiveness reported by the client.
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