ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor. What intervention should the nurse include in the teaching?
- A. Administer antiseizure medications promptly.
- B. Use oral airway devices during seizures.
- C. Pad the side rails of the bed.
- D. Apply restraints during the seizure to prevent injury.
Correct answer: C
Rationale: The correct intervention the nurse should include in the teaching is to pad the side rails of the bed. By padding the side rails, the nurse can help prevent injury if the patient experiences a seizure. Administering antiseizure medications promptly (Choice A) is typically the responsibility of a healthcare provider or according to a prescribed schedule. Using oral airway devices during seizures (Choice B) can pose risks and should be managed by healthcare professionals. Applying restraints during a seizure (Choice D) is not recommended as it can lead to further injury and complications.
2. A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?
- A. Administer oxytocin
- B. Perform fundal massage
- C. Administer IV fluids
- D. Call the provider
Correct answer: B
Rationale: Performing fundal massage is the priority action in this scenario. Fundal massage helps contract the uterus, which is essential in reducing excessive lochia postpartum. Administering oxytocin may be indicated later, but fundal massage should be the initial intervention to address the issue. Administering IV fluids may not directly address the cause of excessive lochia, and calling the provider should come after implementing immediate nursing interventions.
3. The client with atrial fibrillation is receiving warfarin (Coumadin). Which laboratory test should be monitored to determine the effectiveness of the therapy?
- A. Prothrombin time (PT) and international normalized ratio (INR)
- B. Activated partial thromboplastin time (aPTT)
- C. Complete blood count (CBC)
- D. Fibrinogen level
Correct answer: A
Rationale: Monitoring Prothrombin time (PT) and international normalized ratio (INR) is crucial when a client is on warfarin therapy. These tests assess the clotting ability of the blood and help determine the appropriate dosage of warfarin to prevent complications such as bleeding or clotting events. PT and INR values within the therapeutic range indicate the effectiveness of warfarin in managing atrial fibrillation. Choice B, activated partial thromboplastin time (aPTT), is not typically used to monitor warfarin therapy; it is more commonly used to assess the effectiveness of heparin therapy. Choice C, complete blood count (CBC), does not directly assess the anticoagulant effect of warfarin. Choice D, fibrinogen level, is not a primary test for monitoring warfarin therapy; it is more relevant in assessing conditions like disseminated intravascular coagulation.
4. In a client with liver cirrhosis experiencing confusion and disorientation, what condition is most likely causing these symptoms?
- A. Hepatic encephalopathy
- B. Hypoglycemia
- C. Electrolyte imbalance
- D. Dehydration
Correct answer: A
Rationale: Hepatic encephalopathy is the most likely condition causing confusion and disorientation in a client with liver cirrhosis. This condition is a common complication of liver cirrhosis and is characterized by cognitive impairment due to elevated ammonia levels in the blood. The build-up of ammonia affects brain function, leading to symptoms such as confusion, disorientation, and altered consciousness. Hypoglycemia (choice B) may present with confusion but is less likely in a client with liver cirrhosis without a history of diabetes or insulin use. Electrolyte imbalance (choice C) and dehydration (choice D) can contribute to confusion but are not the primary causes in a client with liver cirrhosis experiencing these symptoms.
5. A client has a new diagnosis of nephrotic syndrome, and the nurse is providing dietary management education. Which of the following statements should the nurse include in the teaching?
- A. You should increase your intake of high-sodium foods.
- B. You should decrease your intake of high-sodium foods.
- C. You should avoid foods that contain lactose.
- D. You should increase your intake of dairy products.
Correct answer: B
Rationale: For a client with nephrotic syndrome, decreasing the intake of high-sodium foods is essential to manage fluid retention and symptoms of the condition. Excessive sodium can lead to fluid retention, swelling, and worsen the condition. Therefore, advising the client to decrease their high-sodium food intake aligns with the dietary management approach to help control nephrotic syndrome. Choices A, C, and D are incorrect. Increasing high-sodium foods would exacerbate fluid retention, avoiding lactose is not specifically required for nephrotic syndrome, and increasing dairy products may not be necessary unless individualized based on the client's needs and lab values.
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