ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A community health nurse is reviewing primary prevention for West Nile virus with a group of patients in a rural health clinic. What instructions should the nurse include?
- A. Eliminate areas of standing water.
- B. Wear a mask when outdoors.
- C. Ensure food is cooked thoroughly.
- D. Avoid contact with sick individuals.
Correct answer: A
Rationale: The correct answer is A: 'Eliminate areas of standing water.' Standing water provides breeding grounds for mosquitoes, which spread West Nile virus. By eliminating standing water, individuals can reduce the risk of mosquito breeding and the transmission of the virus. Choices B, C, and D are incorrect. Wearing a mask when outdoors, ensuring food is cooked thoroughly, and avoiding contact with sick individuals are not directly related to primary prevention strategies for West Nile virus.
2. A healthcare provider is caring for four clients. Which of the following tasks can the healthcare provider delegate to an assistive personnel?
- A. Perform chest compressions during cardiac resuscitation
- B. Perform a dressing change for a new amputee
- C. Assess the effectiveness of antiemetic medication
- D. Provide discharge instructions
Correct answer: A
Rationale: Performing chest compressions during cardiac resuscitation is a critical life-saving intervention that can be delegated to an assistive personnel during an emergency. This task requires immediate action and basic training, making it appropriate for delegation. Performing a dressing change for a new amputee involves specialized knowledge and skills, typically performed by licensed healthcare providers. Assessing the effectiveness of medication requires critical thinking and decision-making skills that are within the scope of a licensed healthcare provider. Providing discharge instructions involves educating the patient on post-discharge care and follow-up, which is typically done by a healthcare provider to ensure clear communication and understanding.
3. A nurse in the emergency department is caring for a patient who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the patient’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?
- A. Infection
- B. Airway obstruction
- C. Fluid imbalance
- D. Pain management
Correct answer: B
Rationale: When a patient has extensive burns involving the head, neck, and chest, the priority concern is airway obstruction. The proximity of the burns to the airway can lead to swelling and compromise the patient's ability to breathe. In this situation, ensuring a clear airway and adequate oxygenation takes precedence over other risks such as infection, fluid imbalance, or pain management. While these are also important considerations in burn care, the immediate threat to the patient's life from airway compromise makes it the priority for assessment and intervention.
4. A nurse is caring for a client receiving corticosteroids. Which of the following should the nurse monitor?
- A. Blood glucose levels
- B. Blood pressure
- C. Serum potassium levels
- D. Both A and B
Correct answer: D
Rationale: When a client is receiving corticosteroids, the nurse should monitor both blood glucose levels and blood pressure. Corticosteroids can elevate blood glucose levels, leading to hyperglycemia, and may cause hypertension. Monitoring these parameters is essential to detect and address any potential adverse effects promptly. While monitoring serum potassium levels is important in some situations, it is not a primary concern when caring for a client receiving corticosteroids. Therefore, choices A and B are the most appropriate options for monitoring in this scenario, making option D the correct answer.
5. A charge nurse is discussing HIPAA with a newly licensed nurse. Which action should the charge nurse include in the teaching as an example of a HIPAA violation?
- A. Faxing a patient’s discharge summary to the pharmacy.
- B. Emailing the patient’s positive hepatitis results from an unencrypted server.
- C. Discussing the patient’s care plan during bedside rounds.
- D. Placing the patient’s chart in a secure location at the nurse’s station.
Correct answer: B
Rationale: Emailing patient information from an unencrypted server violates HIPAA because it exposes sensitive health information to potential breaches. Choice A is not a violation as long as the fax is sent to the correct recipient. Choice C is not a violation if the discussion is done discreetly and within an appropriate setting. Choice D is a recommended practice to ensure patient information is kept secure.
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