ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse in a provider’s office is interviewing a client who is requesting an oral contraceptive. Which of the following findings in the client’s history is a contraindication to the use of combination oral contraceptives?
- A. Thyroid disease
- B. Allergy to penicillin
- C. Impaired liver function
- D. Abnormal blood glucose
Correct answer: C
Rationale: Impaired liver function is a contraindication to combination oral contraceptives. The liver metabolizes hormones, and any impairment can affect the metabolism of hormones, potentially leading to imbalances or toxicity. Thyroid disease, allergy to penicillin, and abnormal blood glucose levels are not contraindications to combination oral contraceptives.
2. The client has undergone a thyroidectomy, and the nurse is providing care. Which assessment finding requires immediate intervention?
- A. Hoarseness and a sore throat.
- B. Difficulty swallowing.
- C. Numbness and tingling around the mouth.
- D. Temperature of 100.2°F (37.9°C).
Correct answer: C
Rationale: Numbness and tingling around the mouth can indicate hypocalcemia, a common complication post-thyroidectomy due to inadvertent parathyroid gland removal. Immediate intervention is required to prevent severe hypocalcemia manifestations like tetany or seizures. Hoarseness and a sore throat are common after a thyroidectomy due to surgical trauma and irritation to the vocal cords, not requiring immediate intervention. Difficulty swallowing can be expected due to postoperative swelling or edema, but it should be monitored closely. A temperature of 100.2°F is a mild fever and may be a normal postoperative response, not necessitating immediate intervention unless accompanied by other concerning symptoms.
3. A client who is at 40 weeks gestation and in active labor has 6 cm of cervical dilation and 100% cervical effacement. The client's blood pressure reading is 82/52 mm Hg. Which of the following nursing interventions should the nurse perform?
- A. Prepare for a cesarean birth.
- B. Assist the client to an upright position.
- C. Prepare for an immediate vaginal delivery.
- D. Assist the client to turn onto her side.
Correct answer: D
Rationale: Turning the client onto her side is the appropriate nursing intervention in this scenario. This position can help improve blood pressure by enhancing venous return, which may aid in increasing perfusion to vital organs. It can also alleviate pressure on the inferior vena cava, promoting better circulation and supporting blood pressure stabilization during labor. Choices A, B, and C are incorrect. A cesarean birth is not indicated based on the information provided. Assisting the client to an upright position may worsen her blood pressure due to decreased venous return. Lastly, there is no indication for an immediate vaginal delivery solely based on the client's blood pressure reading.
4. When caring for a patient who just received a terminal diagnosis and is tearful and frightened, what is the best action to demonstrate caring?
- A. Call the patient's spiritual leader to talk to the patient.
- B. Call the patient's family and ask them to come sit with the patient.
- C. Cry with the patient while sympathizing with their situation.
- D. Sit with the patient and listen to their fears.
Correct answer: D
Rationale: In situations where a patient receives a terminal diagnosis and is emotionally distressed, it is essential to provide empathy and support. Sitting with the patient and actively listening to their fears allows the patient to express their emotions and concerns. This action demonstrates genuine care and compassion, showing the patient that their feelings are acknowledged and valued. It creates a therapeutic environment that fosters trust and emotional well-being, helping the patient cope with the distressing news. Calling the patient's spiritual leader (Choice A) may not address the immediate emotional needs of the patient. Calling the patient's family (Choice B) can be comforting but might not directly address the patient's fears. Crying with the patient (Choice C) can blur professional boundaries and may not be as beneficial as actively listening and providing support.
5. A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field?
- A. Place the cap from the solution sterile side up on a clean surface.
- B. Open the outermost flap of the sterile kit away from the body.
- C. Place the sterile dressing within 1.25 cm (0.5 in) of the edge of the sterile field.
- D. Set up the sterile field 5 cm (2 in) above waist level.
Correct answer: A
Rationale: To maintain the sterility of the field, the nurse should place the cap from the solution sterile side up on a clean surface. This action helps prevent contamination. Choice B is incorrect because opening the outermost flap toward the body increases the risk of introducing contaminants onto the sterile field. Choice C is incorrect as the sterile dressing should be placed at least 2.5 cm (1 in) from the edge of the sterile field to prevent accidental contamination. Choice D is incorrect because setting up the sterile field above waist level could lead to inadvertent contact and compromise the field's sterility.
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