ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A healthcare professional is assessing a client for signs of dehydration. Which of the following findings should the healthcare professional look for?
- A. Edema
- B. Dry mucous membranes
- C. Weight gain
- D. Increased urination
Correct answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration. In dehydration, the body loses more water than it takes in, leading to dryness of mucous membranes like the mouth and throat. Edema (choice A) is swelling caused by excess fluid trapped in the body's tissues, which is not a typical sign of dehydration. Weight gain (choice C) is also not a common sign of dehydration; in fact, dehydration usually leads to weight loss. Increased urination (choice D) is more indicative of conditions like diabetes or diuretic use, not dehydration.
2. A healthcare provider is reviewing the medical records of a group of older adults (OA). The provider should identify that which of the following is a risk factor that places OA at an increased risk for developing infections?
- A. Improved circulation
- B. Increased immune function
- C. Lowered immune system function
- D. Dehydration
Correct answer: C
Rationale: The correct answer is C: 'Lowered immune system function.' As individuals age, their immune system tends to weaken, making them more susceptible to infections. Choices A, B, and D are incorrect because improved circulation and increased immune function would typically reduce the risk of infections, while dehydration can impact overall health but is not directly related to immune system function in the context of infection risk.
3. A nurse is caring for a client prescribed ferrous sulfate for the treatment of anemia. Which of the following instructions should be included in client teaching about this medication?
- A. Take the medication on an empty stomach
- B. Notify your provider if your stool becomes dark green
- C. Decrease dietary fiber intake while taking this medication
- D. Take prescribed antacids at the same time as this medication
Correct answer: A
Rationale: The correct instruction for a client prescribed ferrous sulfate for anemia is to take the medication on an empty stomach. This is because ferrous sulfate is best absorbed in an acidic environment, which is enhanced on an empty stomach. However, if the client experiences gastrointestinal side effects, they can take the medication with food. Choice B, notifying the provider if stool becomes dark green, is correct because dark or black stools are common with iron therapy and not a cause for concern. Choice C, decreasing dietary fiber intake, is incorrect as dietary fiber does not interfere with the absorption of ferrous sulfate. Choice D, taking prescribed antacids at the same time, is incorrect as antacids can decrease the absorption of ferrous sulfate.
4. A nurse is planning to delegate client assignments to the assistive personnel. Which of the following tasks is appropriate for the nurse to delegate?
- A. Adjust the flow rate of the client’s oxygen tank
- B. Collect a urine sample
- C. Measure the client’s pain level
- D. Monitor blood glucose levels
Correct answer: B
Rationale: The correct answer is B: Collect a urine sample. Delegating this task to assistive personnel is appropriate as it falls within their scope of practice. Tasks like adjusting the flow rate of oxygen tanks, measuring pain levels, and monitoring blood glucose levels require clinical judgment and should be performed by a nurse. It is important for nurses to delegate tasks that align with the competencies of assistive personnel to ensure safe and effective patient care.
5. A nurse is caring for a client with congestive heart failure. Which of the following prescriptions should the nurse anticipate?
- A. Call the provider if the respiratory rate is less than 18/min
- B. Administer a 500 mL IV bolus of 0.9% sodium chloride over 1 hour
- C. Administer enalapril 2.5 mg PO twice daily
- D. Call the provider if the client’s pulse rate is less than 80/min
Correct answer: C
Rationale: Enalapril, an ACE inhibitor, is commonly prescribed to manage hypertension and heart failure. It helps reduce the workload on the heart and prevent fluid retention. Options A, B, and D are incorrect. Option A focuses on a respiratory rate, which is not specific to heart failure management. Option B suggests administering a large IV bolus of fluid, which can worsen heart failure by increasing fluid volume. Option D addresses the pulse rate, which is not a typical parameter to monitor for heart failure specifically.
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