ATI LPN
PN ATI Capstone Maternal Newborn
1. A client who has been prescribed oral contraception receives education from a nurse. Which of the following client statements indicates a need for further education?
- A. If I miss one pill, I'll take it as soon as possible
- B. If I miss two pills, I'll double up for two days
- C. If I miss three pills, I'll double up each day until back on schedule
- D. I'll use an alternative form of contraception if I miss more than two pills
Correct answer: C
Rationale: The correct course of action after missing oral contraceptive pills depends on how many pills are missed. If three pills are missed, the client should not 'double up' but rather follow the manufacturer's instructions and use an alternative form of contraception until the next cycle. Taking too many pills at once increases the risk of side effects without restoring contraceptive protection. Choices A, B, and D demonstrate understanding of the correct actions to take after missing a pill or two, emphasizing the importance of not doubling up but following specific guidelines to maintain effectiveness and safety.
2. A client with a history of atrial fibrillation is prescribed dabigatran (Pradaxa). Which instruction should the nurse include in the client's teaching?
- A. Take the medication with food to improve absorption.
- B. Avoid foods high in vitamin K.
- C. Take the medication at the same time each day.
- D. Increase your intake of high-potassium foods.
Correct answer: C
Rationale: The correct instruction for the nurse to include in the client's teaching regarding dabigatran (Pradaxa) is to take the medication at the same time each day. This ensures a consistent blood level and effectiveness of the medication, which is crucial in managing atrial fibrillation and preventing complications. It helps maintain a steady therapeutic effect and reduces the risk of erratic drug levels in the body.
3. Aspirin is prescribed for a 9-year-old child with rheumatic fever to control the inflammatory process, promote comfort, and reduce fever. What intervention is most important for the nurse to implement?
- A. Instruct the parents to hold the aspirin until the child has first had a tepid sponge bath.
- B. Administer the aspirin with at least two ounces of water or juice.
- C. Notify the healthcare provider if the child complains of ringing in the ears.
- D. Advise the parents to question the child about seeing yellow halos around objects.
Correct answer: C
Rationale: In children, ringing in the ears (tinnitus) can be a sign of aspirin toxicity. Aspirin toxicity can be particularly concerning in children and can lead to serious complications. Therefore, it is crucial for the nurse to prioritize monitoring for signs of aspirin toxicity, such as tinnitus, and promptly notify the healthcare provider if such symptoms occur.
4. What is the primary purpose of therapeutic communication in healthcare?
- A. To gather client information.
- B. To provide client education.
- C. To establish a therapeutic relationship.
- D. To document client care.
Correct answer: C
Rationale: The primary purpose of therapeutic communication in healthcare is to establish a therapeutic relationship between the healthcare provider and the client. Through effective communication, trust, empathy, and understanding can be fostered, which are essential for providing quality care and promoting positive health outcomes. Building a therapeutic relationship enhances patient satisfaction, improves adherence to treatment plans, and increases the likelihood of successful health outcomes.
5. A client who is 2 days postoperative reports severe pain and swelling in the right leg. The nurse notes that the leg is warm and red. What is the nurse's priority action?
- A. Apply a warm compress to the affected leg.
- B. Elevate the leg on pillows.
- C. Measure the circumference of the leg.
- D. Notify the healthcare provider immediately.
Correct answer: D
Rationale: The nurse's priority action in this situation is to notify the healthcare provider immediately. These symptoms, including severe pain, swelling, warmth, and redness in the leg, are indicative of deep vein thrombosis (DVT), a potentially serious condition. Prompt notification of the healthcare provider is crucial to initiate appropriate diagnostic tests and interventions to prevent complications associated with DVT. Applying a warm compress (Choice A) could worsen the condition by increasing blood flow. Elevating the leg (Choice B) might be contraindicated in DVT as it can dislodge a clot. Measuring the circumference of the leg (Choice C) is not the priority at this time compared to promptly involving the healthcare provider.
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