ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A client who is 8 hours postpartum asks the nurse if she will need to receive Rh immune globulin. The client is gravida 2, para 2, and her blood type is AB negative. The newborn’s blood type is B positive. Which of the following statements is appropriate?
- A. You only need to receive Rh immune globulin if you have a positive blood type.
- B. You should receive Rh immune globulin within 72 hours of delivery.
- C. Both you and your baby should receive Rh immune globulin at your 6-week appointment.
- D. Immune globulin is not necessary since this is your second pregnancy.
Correct answer: B
Rationale: The correct answer is B. Rh-negative mothers who give birth to an Rh-positive baby should receive Rh immune globulin within 72 hours of delivery to prevent the development of antibodies in future pregnancies. Choice A is incorrect because Rh-negative individuals are the ones who require Rh immune globulin. Choice C is incorrect as the administration of Rh immune globulin is time-sensitive and not typically scheduled for a 6-week appointment. Choice D is incorrect because Rh immune globulin is necessary to prevent sensitization regardless of the number of pregnancies.
2. A client is postoperative following a rhinoplasty, and a nurse is contributing to the plan of care. Which of the following interventions should the nurse recommend?
- A. Administer humidified oxygen
- B. Restrict fluids
- C. Instruct the client to avoid the Valsalva maneuver
- D. Apply heat packs to the nose
Correct answer: C
Rationale: Instructing the client to avoid the Valsalva maneuver is crucial after rhinoplasty to reduce strain and the risk of bleeding. Administering humidified oxygen may not be directly related to postoperative care for rhinoplasty. Restricting fluids is not typically necessary unless specifically indicated by the healthcare provider. Applying heat packs to the nose is contraindicated after rhinoplasty as it can increase the risk of bleeding and should be avoided.
3. The client with a diagnosis of heart failure is receiving furosemide (Lasix). Which laboratory value is most important for the nurse to monitor?
- A. Blood glucose
- B. Serum sodium
- C. Serum potassium
- D. Blood urea nitrogen (BUN)
Correct answer: C
Rationale: The correct answer is C: Serum potassium. When a client is receiving furosemide, a loop diuretic, it can lead to potassium loss. Monitoring the serum potassium levels is crucial to prevent life-threatening complications such as cardiac arrhythmias. Blood glucose (Choice A) is not directly impacted by furosemide. Serum sodium (Choice B) may be affected, but monitoring potassium is more critical due to the risk of arrhythmias. Blood urea nitrogen (BUN) (Choice D) is important for assessing kidney function but is not the most crucial value to monitor in a client taking furosemide.
4. A client with peripheral arterial disease complains of leg pain while walking. The nurse should reinforce which teaching point with the client?
- A. Wear compression stockings daily.
- B. Increase daily walking distance gradually.
- C. Elevate legs above heart level when resting.
- D. Use a heating pad to soothe leg muscles.
Correct answer: B
Rationale: For clients with peripheral arterial disease experiencing leg pain while walking, the priority teaching point is to gradually increase daily walking distance. This approach helps improve circulation, build tolerance, and reduce symptoms over time. While compression stockings can be beneficial for circulation, they are not the priority teaching point in this scenario. Elevating legs above heart level when resting is more appropriate for clients with venous insufficiency, not peripheral arterial disease. Using a heating pad is not recommended as it can potentially cause burns or skin damage in clients with compromised circulation.
5. The school staff has been alerted to the fact that an 8-year-old boy routinely playacts as a police officer ‘locking up’ other children on the playground to the point where the children get scared. The staff recognizes that this behavior is most likely an indication of:
- A. The need to dominate others
- B. Inventing traumatic events
- C. A need to develop close relationships
- D. A potential symptom of traumatization
Correct answer: D
Rationale: This behavior of playacting as a police officer and 'locking up' other children to the point of causing fear may suggest that the child is displaying potential symptoms of traumatization. It could indicate that the child has experienced or witnessed traumatic events, leading to the replication of such scenarios as a coping mechanism or way to process the trauma. Choices A, B, and C are incorrect because the behavior described is more indicative of a potential trauma response rather than a need to dominate others, invent traumatic events, or develop close relationships.
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