ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A healthcare provider is assessing a client for allergies before administering propofol. Which of the following allergies is a contraindication to the medication?
- A. Eggs
- B. Milk
- C. Shrimp
- D. Peanuts
Correct answer: A
Rationale: The correct answer is A: Eggs. Propofol is contraindicated in clients with egg allergies because it contains egg lecithin, which can trigger allergic reactions in sensitive individuals. Milk, shrimp, and peanuts are not contraindications for propofol administration.
2. A nurse is caring for a client prescribed lisinopril. Which of the following medication interactions should the nurse instruct this client about?
- A. Potassium supplements
- B. Ciprofloxacin
- C. Escitalopram
- D. Magnesium supplements
Correct answer: A
Rationale: The correct answer is A: Potassium supplements. Lisinopril, an ACE inhibitor, can increase potassium levels in the body. Therefore, the nurse should instruct the client to avoid potassium supplements to prevent hyperkalemia, a potentially dangerous condition. Choices B, C, and D are incorrect because they do not have significant interactions with lisinopril that would lead to adverse effects like hyperkalemia.
3. A nurse is providing discharge instructions about breast engorgement to a client who has decided not to breastfeed. Which of the following statements by the client indicates a need for further instruction?
- A. I can wear a supportive bra
- B. I will apply cold compresses to my breasts
- C. I will manually express breast milk
- D. I can take a mild analgesic
Correct answer: C
Rationale: The correct answer is C. Manually expressing breast milk will stimulate more milk production, which contradicts the goal of reducing milk supply in clients who choose not to breastfeed. Choices A, B, and D are correct statements that can help relieve breast engorgement without promoting further milk production.
4. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take first?
- A. Encourage the client to listen to music
- B. Ask the client what the voices are saying
- C. Provide the client with a distraction
- D. Administer an antipsychotic medication
Correct answer: B
Rationale: Asking the client what the voices are saying is the priority action as it helps assess the content of the hallucinations. This assessment is crucial to determine if the client is at risk of harm to themselves or others. Encouraging the client to listen to music or providing a distraction may not address the underlying issues related to the hallucinations. Administering antipsychotic medication, although important, should come after a thorough assessment of the hallucinations to ensure the right medication and dosage are provided.
5. A nurse is caring for an older adult patient who is disoriented and has a history of falls. What actions should the nurse take?
- A. Place the bed in the lowest position, instruct the patient to remain in bed, ensure the bedside table is within reach.
- B. Instruct the patient to use the call light, apply an ambulation alarm to the patient’s leg, check on the patient hourly.
- C. Assign a sitter to monitor the patient, raise the bed rails, provide the patient with a call button.
- D. Check on the patient every two hours, provide verbal reminders to use the call light, lock the bed wheels.
Correct answer: B
Rationale: In this scenario, the correct actions for the nurse to take involve ensuring patient safety and fall prevention measures. Choice B is the correct answer because instructing the patient to use the call light allows them to signal for help, applying an ambulation alarm helps detect movement, and checking on the patient hourly increases monitoring frequency. These actions are essential for preventing falls in a disoriented patient with a history of falls. Choices A, C, and D are incorrect: A does not provide adequate monitoring or fall prevention measures, C relies solely on assigning a sitter without utilizing technological aids, and D lacks continuous monitoring and specific fall prevention strategies.
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