ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is assessing a 2-hour-old newborn for cold stress. Which of the following findings should the nurse expect?
- A. Respiratory rate of 60/min
- B. Jitteriness of the hands
- C. Diaphoresis
- D. Bounding peripheral pulses
Correct answer: B
Rationale: The correct answer is B: Jitteriness of the hands. Jitteriness is a key sign of cold stress in a newborn, indicating the need for immediate warming measures. A respiratory rate of 60/min may not be directly indicative of cold stress. Diaphoresis (excessive sweating) and bounding peripheral pulses are not typical findings associated with cold stress in newborns.
2. What are the key interventions in managing a patient with diabetic ketoacidosis (DKA)?
- A. Administer insulin and fluids
- B. Administer oral hypoglycemics
- C. Administer glucagon
- D. Administer insulin and monitor blood glucose
Correct answer: A
Rationale: The correct intervention in managing a patient with diabetic ketoacidosis (DKA) is to administer insulin and fluids. Insulin is crucial to correct hyperglycemia, while fluids are important to address dehydration. Administering oral hypoglycemics (Choice B) is not appropriate in the management of DKA as the patient may not be able to absorb oral medications due to gastrointestinal issues. Glucagon (Choice C) is not indicated in the treatment of DKA. Although monitoring blood glucose (Choice D) is important, it is not the sole key intervention for managing DKA; administering insulin and fluids are the primary interventions.
3. When developing a care plan for a patient with generalized anxiety disorder (GAD), which long-term goal is most appropriate?
- A. The patient will experience no episodes of anxiety.
- B. The patient will recognize and modify anxiety-provoking thoughts.
- C. The patient will avoid situations that cause anxiety.
- D. The patient will take medication as prescribed.
Correct answer: B
Rationale: The most appropriate long-term goal for managing generalized anxiety disorder is for the patient to recognize and modify anxiety-provoking thoughts. By addressing and modifying these thoughts, the patient can develop coping mechanisms and strategies to manage their anxiety more effectively in the long term. Choices A and C are not ideal long-term goals as complete elimination of anxiety episodes or avoidance of anxiety-provoking situations may not be realistic or sustainable. Choice D focuses solely on medication adherence, which is important but does not address the core cognitive-behavioral aspects of managing anxiety in GAD.
4. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take to prevent atelectasis?
- A. Encourage deep breathing exercises
- B. Encourage the client to cough every 2 hours
- C. Administer an incentive spirometer
- D. Assist the client to ambulate in the hallway
Correct answer: C
Rationale: The correct answer is C: Administer an incentive spirometer. Using an incentive spirometer helps prevent atelectasis by encouraging lung expansion after surgery. Encouraging deep breathing exercises (choice A) is beneficial but may not be as effective as an incentive spirometer. Encouraging the client to cough (choice B) helps with airway clearance but does not directly prevent atelectasis. Assisting the client to ambulate (choice D) is important for preventing complications such as deep vein thrombosis, but it is not the most effective intervention for preventing atelectasis.
5. When managing Akosua Adepa, an eight-year-old diagnosed with Asthma, the nurse will consider the following as complications EXCEPT:
- A. Cor pulmonale
- B. Respiratory arrest
- C. Respiratory distress
- D. Respiratory failure
Correct answer: C
Rationale: When managing a pediatric patient with asthma, the nurse needs to be vigilant about potential complications. While cor pulmonale, respiratory arrest, and respiratory failure are known complications of asthma, respiratory distress is not typically considered a direct complication. Respiratory distress is more of a symptom or a sign of worsening asthma, indicating the need for immediate intervention to prevent progression to more severe complications.
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