ATI LPN
PN ATI Capstone Maternal Newborn
1. A client has been prescribed raloxiphene. As the nurse, you know that raloxiphene is used to treat:
- A. Migraines
- B. Hypertension
- C. Osteoporosis
- D. Heart disease
Correct answer: C
Rationale: Raloxiphene (Evista) is a selective estrogen receptor modulator (SERM) used primarily to prevent and treat osteoporosis in postmenopausal women. It helps to maintain bone density and reduce the risk of fractures by mimicking the effects of estrogen on bone tissue. It is not indicated for the treatment of migraines, hypertension, or heart disease. Therefore, the correct answer is osteoporosis (Choice C). Choices A, B, and D are incorrect as raloxiphene is not used to treat migraines, hypertension, or heart disease.
2. A client who has undergone a cesarean birth is receiving discharge instructions from a nurse. Which of the following should the nurse include in the instructions?
- A. Limit stair climbing for the first few weeks
- B. Avoid lifting anything heavier than the newborn
- C. Use a pillow to support the abdomen when coughing or sneezing
- D. All of the above
Correct answer: D
Rationale: After a cesarean birth, it is important for the client to follow specific instructions for optimal recovery. Limiting stair climbing reduces strain on the incision site, aiding in healing (Choice A). Avoiding lifting anything heavier than the newborn prevents stress on the incision, promoting recovery (Choice B). Using a pillow to support the abdomen during coughing or sneezing helps reduce discomfort and protect the incision, preventing sudden movements or strain (Choice C). Therefore, all the options provided are crucial post-cesarean birth instructions to ensure proper healing and recovery. Choices A, B, and C are all essential components of post-cesarean care, making Option D the correct answer.
3. A nurse is caring for an older adult who has a non-palpable skin lesion that is less than 0.5 cm in diameter. Which term should the nurse use to document this finding?
- A. Vesicle
- B. Macule
- C. Papule
- D. Nodule
Correct answer: B
Rationale: The correct answer is B: Macule. A macule is a non-palpable skin lesion smaller than 1 cm in diameter. In this case, the skin lesion described is less than 0.5 cm, making it consistent with a macule. Vesicle (choice A) is a small blister filled with clear fluid, papule (choice C) is a solid, raised skin lesion less than 0.5 cm in diameter, and nodule (choice D) is a palpable, solid lesion larger than 0.5 cm in diameter. Therefore, choices A, C, and D describe skin lesions that do not match the characteristics of the lesion presented in the question.
4. A nurse is preparing to administer lactated Ringer's (LR) 1,000 mL IV to infuse over 8 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?
- A. 19 gtt/min
- B. 20 gtt/min
- C. 21 gtt/min
- D. 22 gtt/min
Correct answer: C
Rationale: Calculation: 1000 mL / 480 minutes × 10 gtt/mL = 20.83, rounded to 21 gtt/min. This ensures proper IV fluid administration over the prescribed time. Choice C is the correct answer as it reflects the accurate calculation based on the given parameters. Choice A is incorrect because it does not accurately calculate the infusion rate. Choice B is incorrect as it does not consider the precise calculation required. Choice D is incorrect as it deviates from the correct calculation.
5. A nurse is preparing to administer a blood transfusion. Which of the following actions should the nurse take first?
- A. Obtain the client's consent
- B. Verify the blood type and crossmatch
- C. Take baseline vital signs
- D. Prime the IV with normal saline
Correct answer: B
Rationale: The correct first action the nurse should take when preparing to administer a blood transfusion is to verify the blood type and crossmatch. This step is crucial to ensure compatibility and prevent transfusion reactions. Obtaining the client's consent is important but should follow the verification process. Taking baseline vital signs is necessary before starting the transfusion, but confirming compatibility takes precedence. Priming the IV with normal saline is a step done before starting the transfusion, after ensuring blood compatibility.
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