ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A nurse enters a patient's room and finds the client pulseless. The living will requests no resuscitation be performed, but the provider has not written the prescription. What action should the nurse take?
- A. Notify the family.
- B. Begin CPR.
- C. Await further instructions from the provider.
- D. Document the event.
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to begin CPR. Even though the living will requests no resuscitation, without a written do-not-resuscitate (DNR) order from the provider, the nurse is ethically and legally bound to initiate CPR to provide life-saving measures until further confirmation is obtained. Notifying the family (Choice A) may cause a delay in providing immediate care. Waiting for further instructions (Choice C) can be time-consuming and compromise patient outcomes. Documenting the event (Choice D) is important but should follow after initiating CPR to ensure patient safety and adherence to protocols.
2. A nurse in an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness. The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox?
- A. Bloody diarrhea
- B. Ptosis of the eyelids
- C. Descending paralysis
- D. Rash in the mouth
Correct answer: D
Rationale: The correct answer is D, 'Rash in the mouth.' Smallpox presents with a distinctive rash that typically begins in the mouth and spreads to the rest of the body, developing into pustules. This rash is a key clinical manifestation of smallpox. This infectious disease is characterized by the rash, fever, and other systemic symptoms. Choices A, B, and C are incorrect because they are not associated with smallpox. Bloody diarrhea, ptosis of the eyelids, and descending paralysis are not typical clinical manifestations of smallpox.
3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?
- A. Prealbumin level of 20 mg/dL
- B. Weight increase of 2 kg/day
- C. Temperature of 37.6°C
- D. Blood glucose level of 120 mg/dL
Correct answer: B
Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.
4. A healthcare professional is preparing to administer a dose of naloxone. Which of the following should the healthcare professional assess?
- A. Heart rate
- B. Respiratory rate
- C. Blood pressure
- D. Temperature
Correct answer: B
Rationale: Correct. Naloxone is used to reverse opioid overdose, which can cause respiratory depression. Assessing the respiratory rate before administering naloxone is crucial to monitor the patient's breathing. Choices A, C, and D are important assessments in general patient care but are not specifically crucial before administering naloxone for opioid overdose.
5. A nurse is reviewing dietary assessment findings for a client who is Jewish and observes kosher dietary practices. Which of the following behaviors should the nurse expect to find?
- A. Leavened bread may be eaten during Passover
- B. Shellfish is commonly consumed in the diet
- C. Meat and dairy products are eaten separately
- D. Fasting from meat occurs during Hanukkah
Correct answer: C
Rationale: The correct answer is C. According to kosher dietary laws, meat and dairy products cannot be consumed together. This practice stems from the prohibition in Jewish law against cooking a young animal in its mother's milk. Therefore, the nurse should expect to find that meat and dairy products are eaten separately. Choices A, B, and D are incorrect. Leavened bread is not eaten during Passover (Choice A), shellfish is not consumed in the kosher diet (Choice B), and fasting from meat does not occur during Hanukkah (Choice D).
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