ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day
- B. Initiate seizure precautions for the client
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr
- D. Encourage the client to ambulate twice per day
Correct answer: B
Rationale: The correct action for the nurse to take is to initiate seizure precautions for the client. Severe preeclampsia increases the risk of seizures (eclampsia), making it crucial to prioritize the safety of the client. Restricting protein intake (Choice A) is not the priority in this situation as seizure prevention takes precedence. While maintaining hydration is essential, starting an infusion of 0.9% sodium chloride (Choice C) is not the initial action needed for seizure prevention. Encouraging the client to ambulate (Choice D) may not be safe or appropriate considering the severity of preeclampsia and the risk of seizures.
2. When planning care for a 16-year-old with appendicitis presenting with right lower quadrant pain, what should the nurse prioritize as a nursing diagnosis?
- A. Imbalanced nutrition: Less than body requirements related to decreased oral intake
- B. Risk for infection related to possible rupture of the appendix
- C. Constipation related to decreased bowel motility and decreased fluid intake
- D. Chronic pain related to appendicitis
Correct answer: B
Rationale: The priority nursing diagnosis for a client with appendicitis is the 'Risk for infection related to possible rupture of the appendix.' Appendicitis carries a risk of the appendix rupturing, which can lead to peritonitis, a life-threatening condition. Preventing infection through timely intervention and surgery is critical in the care of a client with appendicitis, making this nursing diagnosis the priority.
3. The client at risk for thrombophlebitis receives reinforcement from the LPN/LVN regarding measures to minimize its occurrence. Which statement by the client indicates an understanding of this information?
- A. I should avoid sitting for prolonged periods.
- B. I will take frequent walks and avoid prolonged bed rest.
- C. I should drink plenty of fluids to stay hydrated.
- D. I will use compression stockings as advised by my doctor.
Correct answer: B
Rationale: The correct answer is B. Taking frequent walks and avoiding prolonged bed rest are essential measures to promote circulation and reduce the risk of thrombophlebitis. Physical activity helps prevent blood from pooling and clotting in the veins, thus decreasing the likelihood of thrombophlebitis development. Choice A is incorrect because while avoiding prolonged sitting is important, it is not as effective as engaging in physical activity. Choice C is not directly related to preventing thrombophlebitis. Choice D, using compression stockings, is a helpful measure but not as effective as regular physical activity in preventing thrombophlebitis.
4. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home?
- A. Family members who smoke should be at least 10 ft away from the client when oxygen is in use
- B. Nail polish should not be used near a client who is receiving oxygen
- C. A 'No Smoking' sign should be placed on the front door
- D. Cotton bedding and clothing should be replaced with items made from wool
Correct answer: C
Rationale: The correct answer is C. Placing a 'No Smoking' sign on the front door is crucial for fire safety when using oxygen at home. Choice A is incorrect as family members who smoke should not be around the client when oxygen is in use, not just at a distance. Choice B is not directly related to oxygen safety. Choice D is also irrelevant as the type of bedding and clothing material does not impact oxygen safety.
5. Which type of family-nurse contact will provide you with the best opportunity to observe family dynamics?
- A. Clinic consultation
- B. Group conferences
- C. Home visit
- D. Written communication
Correct answer: C
Rationale: The best opportunity to observe family dynamics is through a home visit. This setting allows the nurse to observe the family in their natural environment, providing valuable insights into their relationships, interactions, and living conditions. By being present in the home, the nurse can better understand the family dynamics, communication patterns, and potential stressors that may not be evident in other forms of contact such as clinic consultations, group conferences, or written communication.
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