ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A healthcare professional is assessing a client for potential complications after surgery. Which of the following should the healthcare professional monitor for?
- A. Decreased urine output
- B. Increased appetite
- C. Improved mobility
- D. Normal temperature
Correct answer: A
Rationale: Corrected Rationale: Decreased urine output can indicate renal complications or dehydration, which are common post-surgical complications. Monitoring urine output is crucial for detecting early signs of kidney dysfunction or fluid imbalances. Increased appetite, improved mobility, and normal temperature are not typical signs of immediate post-surgical complications and would not be the priority for monitoring in this case.
2. A nurse is caring for a client with Alzheimer’s disease. Which action should the nurse include in the plan of care to support the client’s cognitive function?
- A. Place a daily calendar in the kitchen
- B. Replace buttoned clothing with zippered items
- C. Replace the carpet with hardwood floors
- D. Create variation in the daily routine
Correct answer: A
Rationale: Placing a daily calendar in the kitchen is essential to help clients with Alzheimer's stay oriented to time and maintain cognitive function. It supports their ability to recall the day, date, and upcoming events, promoting a sense of control over their environment. Choices B, C, and D do not directly target cognitive function support in clients with Alzheimer's disease. While replacing buttoned clothing with zippered items may aid in dressing independently, changing the flooring or introducing variation in the daily routine does not specifically address cognitive function support.
3. A nurse is caring for a client receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?
- A. Stop the infusion.
- B. Slow the infusion.
- C. Apply a warm compress to the site.
- D. Apply a cold compress to the site.
Correct answer: A
Rationale: Corrected Rationale: If infiltration is suspected, the nurse should immediately stop the dopamine infusion to prevent further damage to the surrounding tissue. Choice A is the correct answer because continuing the infusion can lead to tissue damage and compromise the client's care. Slowing the infusion (Choice B) is not sufficient to prevent harm and may still cause damage. Applying a warm compress (Choice C) or a cold compress (Choice D) is not the recommended action for infiltration; stopping the infusion is crucial to prevent complications.
4. A nurse is caring for a newborn diagnosed with necrotizing enterocolitis (NEC). Which of the following interventions should the nurse expect to implement?
- A. Withhold oral feedings
- B. Measure abdominal girth
- C. Position the newborn supine
- D. Apply cold compresses to the abdomen
Correct answer: B
Rationale: Measuring abdominal girth is crucial in monitoring for signs of abdominal distension, which is a key indicator of worsening necrotizing enterocolitis (NEC). It helps in assessing the progression of the condition. Positioning the newborn supine, as in choice C, can help relieve pressure on the abdomen but does not directly monitor the condition. Applying cold compresses, as in choice D, is not recommended for NEC as it can constrict blood vessels and potentially worsen the condition. Withholding oral feedings, as in choice A, is also important to rest the bowel and prevent further complications, but measuring abdominal girth is more directly related to monitoring the progression of NEC.
5. A nurse is preparing to perform closed intermittent bladder irrigation for a client following a transurethral resection of the prostate (TURP). Which of the following actions is appropriate by the nurse?
- A. Aspirate the irrigation solution from the bladder
- B. Insert the tip of the irrigation syringe into the catheter opening
- C. Apply sterile gloves
- D. Open the flow clamp to the irrigating fluid infusion tubing
Correct answer: C
Rationale: The correct action for the nurse to take before performing a closed intermittent bladder irrigation is to apply sterile gloves. Sterile gloves help maintain asepsis, reduce the risk of infection, and ensure patient safety during the procedure. Aspirating the irrigation solution from the bladder (Choice A) is not a standard step in closed intermittent bladder irrigation. Inserting the tip of the irrigation syringe into the catheter opening (Choice B) can introduce contaminants into the system. Opening the flow clamp to the irrigating fluid infusion tubing (Choice D) should only be done after ensuring all equipment is ready and the nurse is gloved to maintain sterility.
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