ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A client is prescribed digoxin for heart failure. Which of the following should the nurse monitor to evaluate the effectiveness of the medication?
- A. Respiratory rate
- B. Blood pressure
- C. Apical pulse
- D. Urine output
Correct answer: C
Rationale: The correct answer is C: Apical pulse. Digoxin's primary effect is to strengthen the force of the heart's contractions and slow the heart rate. Monitoring the apical pulse is crucial in evaluating the effectiveness of digoxin as it helps assess the medication's impact on the heart's function. Option A, respiratory rate, is not directly related to digoxin's mechanism of action and is not the most appropriate parameter to monitor for this medication. Option B, blood pressure, while important, may not be as sensitive as the apical pulse in assessing the effectiveness of digoxin. Option D, urine output, is more indicative of kidney function and fluid balance, rather than the direct effectiveness of digoxin in heart failure.
2. A nurse is caring for a client with a new prescription for lisinopril. Which of the following should the nurse monitor?
- A. Blood pressure
- B. Liver function
- C. Serum potassium levels
- D. Heart rate
Correct answer: A
Rationale: Corrected Rationale: Lisinopril is an ACE inhibitor commonly used to lower blood pressure. Monitoring blood pressure is crucial when initiating this medication to assess its effectiveness and potential side effects related to blood pressure regulation. Liver function monitoring is not typically required with lisinopril. While lisinopril can affect potassium levels, it is not the primary parameter to monitor when starting this medication. Heart rate monitoring is not a routine requirement when initiating lisinopril therapy.
3. A client with preeclampsia is receiving magnesium sulfate intravenously. What action should the nurse take if the client develops toxicity?
- A. Position the client supine
- B. Prepare an IV bolus of dextrose 5%
- C. Administer calcium gluconate IV
- D. Administer methylergonovine IM
Correct answer: C
Rationale: In cases of magnesium sulfate toxicity, calcium gluconate is the antidote as it helps reverse the effects. Positioning the client supine (Choice A) may not directly address magnesium sulfate toxicity. Administering dextrose 5% (Choice B) is not the correct intervention for magnesium sulfate toxicity. Methylergonovine IM (Choice D) is used to manage postpartum hemorrhage, not magnesium sulfate toxicity.
4. A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?
- A. Decreased level of consciousness
- B. Inability to identify common objects
- C. Poor problem-solving ability
- D. Preoccupation with somatic disturbances
Correct answer: C
Rationale: Corrected Rationale: Poor problem-solving ability is a common cognitive symptom of schizophrenia. It affects the client's ability to think clearly and make decisions. Decreased level of consciousness (Choice A) is not a typical assessment finding in schizophrenia. Inability to identify common objects (Choice B) is more indicative of conditions like dementia. Preoccupation with somatic disturbances (Choice D) is characteristic of somatic symptom disorders, not schizophrenia.
5. A nurse is assessing a client with pancreatitis. Which of the following findings should the nurse look for?
- A. Increased appetite
- B. Abdominal pain
- C. Weight gain
- D. Elevated blood pressure
Correct answer: B
Rationale: The correct answer is B: Abdominal pain. Abdominal pain, often severe, is a hallmark sign of pancreatitis. Other common symptoms include nausea, vomiting, and tenderness in the abdomen. Choices A, C, and D are incorrect because increased appetite, weight gain, and elevated blood pressure are not typically associated with pancreatitis. Therefore, the nurse should primarily focus on assessing for abdominal pain in a client with suspected pancreatitis.
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