ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. What teaching points are important for the nurse to discuss with a client with hearing loss who has been fitted for a hearing aid?
- A. Use the highest setting to promote full auditory comprehension
- B. Use mild soap and water to clean the ear mold
- C. Turn the hearing aid off to conserve battery life during hours of sleep only
- D. Immerse the hearing aid in saline solution to keep it hygienic
Correct answer: B
Rationale: The correct teaching point for a client with hearing loss who has been fitted for a hearing aid is to use mild soap and water to clean the ear mold. It is important to keep the ear mold clean to prevent infections and maintain proper functioning. Choice A is incorrect because using the highest setting can lead to discomfort and may not be necessary for all situations. Choice C is incorrect as the hearing aid should generally be turned off when not in use, not just during sleep, to conserve battery life. Choice D is incorrect as immersing the hearing aid in saline solution can damage the device; it should be kept dry to prevent malfunction.
2. A nurse is teaching a client about the use of aspirin. Which of the following should be included?
- A. It can cause drowsiness
- B. It should be taken with food
- C. Monitor for signs of bleeding
- D. It is safe during pregnancy
Correct answer: C
Rationale: The correct answer is C: 'Monitor for signs of bleeding.' Aspirin is known to increase the risk of bleeding, so clients should be monitored for this potential side effect. Choice A is incorrect because aspirin is not typically associated with causing drowsiness. Choice B is not a specific consideration for aspirin use; it is not necessary to take it with food. Choice D is incorrect because aspirin is not considered safe during pregnancy and should be avoided, especially in the third trimester, as it may cause complications for the mother and the baby.
3. A nurse is teaching a client about dietary modifications for a low-sodium diet. Which of the following should the nurse include?
- A. Limit intake of processed foods
- B. Increase intake of fresh fruits and vegetables
- C. Use of accessory muscles
- D. Monitor for allergic reactions
Correct answer: A
Rationale: The correct answer is to limit intake of processed foods. Processed foods are often high in sodium, which goes against the goal of a low-sodium diet. Fresh fruits and vegetables are recommended for a low-sodium diet due to their natural low sodium content. The use of accessory muscles and monitoring for allergic reactions are not related to dietary modifications for a low-sodium diet.
4. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day
- B. Initiate seizure precautions for the client
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr
- D. Encourage the client to ambulate twice per day
Correct answer: B
Rationale: The correct action for the nurse to take is to initiate seizure precautions for the client. Severe preeclampsia increases the risk of seizures (eclampsia), making it crucial to prioritize the safety of the client. Restricting protein intake (Choice A) is not the priority in this situation as seizure prevention takes precedence. While maintaining hydration is essential, starting an infusion of 0.9% sodium chloride (Choice C) is not the initial action needed for seizure prevention. Encouraging the client to ambulate (Choice D) may not be safe or appropriate considering the severity of preeclampsia and the risk of seizures.
5. A client is found on the floor of their room experiencing a seizure. Which of the following actions is the priority for the nurse?
- A. Place the client on their side with their head forward
- B. Call for help
- C. Protect the client's head
- D. Restrain the client
Correct answer: A
Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration, which is crucial in managing the client's safety during a seizure. Calling for help is important but ensuring the client's immediate safety by positioning them correctly takes precedence. Protecting the client's head can be done concurrently while positioning the client. Restraint is not appropriate during a seizure as it can lead to injuries and complications.
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