ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A client is prescribed digoxin and has a potassium level of 3.0 mEq/L. Which of the following actions should the nurse take?
- A. Administer digoxin without any modifications
- B. Administer the medication at a lower dose
- C. Monitor serum potassium levels
- D. Discontinue the medication if potassium levels rise
Correct answer: A
Rationale: A potassium level of 3.0 mEq/L indicates hypokalemia, which increases the risk of digoxin toxicity. In this case, the nurse should administer the digoxin without any modifications. Lowering the dose (Choice B) may not be necessary if the potassium level is not critically low. Monitoring serum potassium levels (Choice C) is important but should not delay the administration of digoxin. Discontinuing the medication (Choice D) is not the initial action to take unless the potassium levels become severely low and life-threatening.
2. How should a healthcare provider respond to a patient experiencing a seizure?
- A. Protect the airway and monitor for post-ictal confusion
- B. Administer anticonvulsant medications
- C. Apply restraints to prevent injury
- D. Place the patient in a side-lying position
Correct answer: D
Rationale: When a patient is experiencing a seizure, the immediate priority is to ensure their safety by placing them in a side-lying position. This helps prevent aspiration in case of vomiting and maintains an open airway. Administering anticonvulsant medications is not within the scope of a healthcare provider's immediate response during a seizure. Applying restraints can potentially harm the patient by restricting movement and causing injury. Monitoring for post-ictal confusion is important after the seizure has ended, but the primary concern during the seizure is ensuring the patient's safety.
3. The healthcare provider formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely cause for this nursing diagnosis?
- A. Pain during coughing.
- B. Diminished cough effort.
- C. Thick, dry secretions.
- D. Excessive inflammation.
Correct answer: B
Rationale: Clients with myasthenia gravis commonly experience muscle weakness, including in the muscles used for coughing. This diminished cough effort can lead to ineffective airway clearance, increasing the risk of respiratory complications. Therefore, the most likely cause for the nursing diagnosis 'High risk for ineffective airway clearance' in a client with myasthenia gravis is the diminished cough effort due to muscle weakness.
4. A client who is at 24 weeks of gestation is scheduled for a 1-hour glucose tolerance test. Which of the following statements should the nurse include in her teaching?
- A. You will need to drink the glucose solution 1 hour prior to the test.
- B. Limit your carbohydrate intake for 24 hours prior to the test.
- C. A blood glucose of 130 to 140 mg/dL is considered a positive screening result.
- D. You will need to fast for 8 hours prior to the test.
Correct answer: C
Rationale: The correct statement to include in the teaching for a client scheduled for a 1-hour glucose tolerance test at 24 weeks of gestation is that a blood glucose level of 130 to 140 mg/dL is considered a positive screening result. This range indicates a potential issue with glucose metabolism and would prompt the need for a follow-up 3-hour glucose tolerance test to confirm the diagnosis of gestational diabetes mellitus. Choices A, B, and D are incorrect. In a 1-hour glucose tolerance test, the glucose solution is typically consumed within a specific timeframe before the test, not necessarily 1 hour prior. There is usually no specific requirement to limit carbohydrate intake for 24 hours prior to the test. Fasting for 8 hours prior to the test is more common for a fasting glucose test, not a 1-hour glucose tolerance test.
5. A nurse is providing teaching to a client about the Papanicolaou (Pap) test. Which of the following information should the nurse include in the teaching?
- A. A Pap test is recommended every 3 years for women aged 21-29 and every 3-5 years for women aged 30-65.
- B. Pap tests are recommended following removal of the ovaries.
- C. Avoid having sexual intercourse for 24 hours prior to the Pap test.
- D. Viral infections cannot be detected by a Pap test.
Correct answer: C
Rationale: Clients should avoid sexual intercourse for 24 hours prior to the Pap test to ensure accurate results, as it can affect the sample. This is important for obtaining reliable results. Choice A is incorrect because a yearly Pap test is not the standard recommendation for all age groups; instead, it is typically every 3 years for women aged 21-29 and every 3-5 years for women aged 30-65. Choice B is incorrect because Pap tests are not necessarily discontinued following removal of the ovaries; they may still be needed based on the individual's health history and provider recommendations. Choice D is incorrect because while Pap tests are primarily used to detect abnormal cervical cells and cervical cancer, they do not detect viral infections.
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