ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A healthcare provider is among the first responders to a mass-casualty incident and does not know what type of personal protective equipment (PPE) is needed. Which of the following actions should the healthcare provider take?
- A. Use basic gloves and a mask.
- B. Choose the highest level of protection equipment available.
- C. Use only respiratory protection.
- D. Ask a colleague for advice.
Correct answer: B
Rationale: In situations where the type of hazard is unknown, the healthcare provider should choose the highest level of protection equipment available. This helps ensure adequate protection against any potential hazards that may be present. Using only basic gloves and a mask (Choice A) may not provide sufficient protection if the hazard is more severe. Opting for respiratory protection only (Choice C) may leave other areas of the body vulnerable to exposure. While asking a colleague for advice (Choice D) is good practice in general, in urgent situations like mass-casualty incidents with unknown hazards, it is crucial to prioritize immediate protection by selecting the highest level of PPE.
2. A client with a severe head injury is admitted to the intensive care unit (ICU). Which finding should the nurse report to the healthcare provider immediately?
- A. Urine output of 100 mL/hour.
- B. Intracranial pressure (ICP) of 20 mm Hg.
- C. Respiratory rate of 12 breaths/minute.
- D. Mean arterial pressure (MAP) of 70 mm Hg.
Correct answer: B
Rationale: An Intracranial Pressure (ICP) of 20 mm Hg is at the upper limit of normal and may indicate increased intracranial pressure, which is a critical finding in a client with a severe head injury. Elevated ICP can lead to further brain damage and must be addressed promptly to prevent complications such as herniation. Monitoring and managing ICP are crucial in the care of patients with head injuries in the ICU.
3. The nurse is assisting in the care of a client experiencing an acute myocardial infarction (MI). Which medication would the nurse expect to be administered to help reduce myocardial oxygen demand?
- A. Aspirin
- B. Morphine
- C. Atropine
- D. Lidocaine
Correct answer: B
Rationale: In the context of an acute myocardial infarction (MI), morphine is administered to relieve pain and reduce myocardial oxygen demand. By alleviating pain and anxiety, morphine helps reduce oxygen demand on the heart, which is beneficial in the setting of an MI. Aspirin, commonly used for its antiplatelet effects, helps inhibit platelet aggregation and is crucial in the management of MI to prevent further clot formation. Atropine is a medication used to treat symptomatic bradycardia by increasing heart rate, not commonly indicated in the management of acute MI. Lidocaine is used for ventricular dysrhythmias and is not typically given to reduce myocardial oxygen demand in an acute MI scenario.
4. What assessments should the nurse prioritize for a client with portal hypertension admitted to the medical floor?
- A. Assessment of blood pressure and evaluation for headaches and visual changes
- B. Assessment for signs and symptoms of venous thromboembolism
- C. Daily weights and measurement of abdominal girth
- D. Monitoring blood glucose every 4 hours
Correct answer: C
Rationale: In portal hypertension, daily weights and measurement of abdominal girth are crucial assessments to monitor fluid retention and ascites. These assessments help in evaluating the effectiveness of treatment and identifying any worsening of the condition, guiding appropriate interventions. Monitoring blood pressure and assessing for symptoms like headaches and visual changes may be important but are not the priority in this case. Assessing for signs and symptoms of venous thromboembolism is relevant in some situations but not directly related to the primary concerns of portal hypertension.
5. A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate (TURP). Which of the following should the nurse identify as a priority nursing assessment after reviewing the client's information?
- A. Level of consciousness.
- B. Skin turgor.
- C. Deep-tendon reflexes.
- D. Bowel sounds.
Correct answer: A
Rationale: The correct answer is A: Level of consciousness. Following a TURP procedure, monitoring the client's level of consciousness is crucial as it can indicate potential postoperative complications such as hemorrhage or shock. Skin turgor (choice B) is more related to hydration status, deep-tendon reflexes (choice C) are not the priority post-TURP, and bowel sounds (choice D) are important but not the priority in this situation.
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