ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A client is prescribed tramadol for pain management. Which of the following should the nurse educate the client about?
- A. It is a non-opioid analgesic
- B. It can cause sedation
- C. It has no risk for dependence
- D. It can be taken as needed
Correct answer: B
Rationale: The correct answer is B. Tramadol can cause sedation, so the nurse should educate the client about this potential side effect. Choice A is incorrect because tramadol is actually an opioid analgesic. Choice C is incorrect as tramadol does carry a risk for dependence, especially with prolonged use. Choice D is not entirely accurate as tramadol is usually prescribed on a scheduled basis rather than as needed.
2. A nurse is caring for a client receiving heparin. Which of the following should the nurse monitor?
- A. INR levels
- B. APTT levels
- C. Blood glucose levels
- D. Liver function tests
Correct answer: B
Rationale: Heparin therapy requires monitoring of activated partial thromboplastin time (APTT) to ensure therapeutic levels. APTT reflects the intrinsic pathway of the clotting cascade and is used to assess the effectiveness and safety of heparin therapy. Monitoring INR levels is more relevant for assessing warfarin therapy, not heparin. Blood glucose levels are monitored for clients with diabetes or those on medications affecting glucose levels. Liver function tests are used to assess liver health and are not directly related to monitoring heparin therapy.
3. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client’s contractions are occurring every 45 seconds with a duration of 90 seconds, and the fetal heart rate is 170-180/minute. Which of the following actions should the nurse take?
- A. Discontinue the oxytocin infusion
- B. Increase the oxytocin infusion
- C. Decrease the oxytocin infusion
- D. Maintain the oxytocin infusion
Correct answer: A
Rationale: In this scenario, the contractions are too frequent (tachysystole), and the fetal heart rate is elevated. Tachysystole can lead to decreased oxygen perfusion to the fetus, causing fetal distress. Therefore, the correct action for the nurse to take is to discontinue the oxytocin infusion to prevent harm to both the mother and fetus. Increasing or maintaining the oxytocin infusion would exacerbate the current situation, potentially leading to further complications. Decreasing the oxytocin infusion may not be sufficient to address the tachysystole and elevated fetal heart rate, making it an inappropriate choice.
4. Which of the following exemplifies the school nurse’s health care provider function?
- A. Requesting BCG vaccine from the RHU for school entrance immunization
- B. Conducting random classroom inspections during a measles epidemic
- C. Taking corrective action on an accident hazard in the school playground
- D. Observing areas in the school where pupils spend their free time
Correct answer: B
Rationale: Conducting random classroom inspections during a measles epidemic is a vital function of the school nurse as it involves assessing pupils and teachers for signs of a health problem prevalent in the community. This function helps in early detection, prevention, and control of diseases among students and staff, contributing to maintaining a healthy school environment.
5. A nurse is caring for a client who has chronic kidney disease. Which of the following diets should the nurse anticipate the provider to prescribe?
- A. 4 g sodium diet
- B. Potassium-restricted diet
- C. High phosphorus diet
- D. High protein diet
Correct answer: B
Rationale: Clients with chronic kidney disease often have difficulty regulating potassium levels in their blood. A potassium-restricted diet helps prevent hyperkalemia, a common complication in these clients. High sodium diet (Choice A) is typically avoided in kidney disease to prevent fluid retention and high blood pressure. High phosphorus diet (Choice C) is usually restricted in kidney disease as elevated phosphorus levels can lead to bone and heart problems. While protein is important for overall health, a high protein diet (Choice D) can put extra strain on the kidneys and is usually limited in chronic kidney disease.
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