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 patient with anorexia nervosa is being treated in an inpatient facility. Which intervention should be included in the care plan?
- A. Allowing the patient to eat alone to reduce stress
- B. Monitoring the patient's weight weekly
- C. Encouraging the patient to exercise daily
- D. Providing the patient with a high-calorie diet
Correct answer: B
Rationale: Monitoring the patient's weight weekly is crucial in the care of individuals with anorexia nervosa as it allows healthcare providers to track changes in weight, which is a key indicator of nutritional status. Regular weight monitoring helps in identifying any significant weight loss or gain, enabling prompt intervention and adjustment of the treatment plan to address the patient's nutritional needs effectively.
3. A nurse is preparing to administer an enteral tube feeding through an NG tube at 250 mL over 4 hr. The nurse should set the pump to deliver how many mL/hr? (Round the answer to the nearest whole number)
- A. 63 mL/hr
- B. 36 mL/hr
- C. 78 mL/hr
- D. 90 mL/hr
Correct answer: A
Rationale: To calculate the rate for the enteral tube feeding, divide the total volume by the total time: 250 mL / 4 hr = 62.5 ≈ 63 mL/hr. Therefore, the nurse should set the pump to deliver 63 mL/hr. Choices B, C, and D are incorrect as they do not match the correct calculation result. B is too low, C is too high, and D is also too high based on the correct calculation.
4. What is the first intervention for a patient in shock?
- A. Administer fluids
- B. Monitor blood pressure
- C. Provide oxygen
- D. Call for assistance
Correct answer: A
Rationale: The correct answer is to administer fluids. In a patient experiencing shock, the priority is to address inadequate perfusion by restoring circulating blood volume. Administering fluids helps improve perfusion and oxygen delivery to vital organs. Monitoring blood pressure, providing oxygen, and calling for assistance are important steps but administering fluids is the initial and most critical intervention in the management of shock.
5. A client with a new diagnosis of myasthenia gravis is prescribed pyridostigmine (Mestinon). Which instruction should the nurse include in the client's teaching?
- A. Take the medication with food to prevent gastrointestinal upset.
- B. Take the medication 30 minutes before meals.
- C. Avoid dairy products while taking this medication.
- D. Take the medication at bedtime.
Correct answer: B
Rationale: The correct instruction for a client with myasthenia gravis prescribed pyridostigmine (Mestinon) is to take the medication 30 minutes before meals. This timing is crucial as it helps improve muscle strength for eating and swallowing. By taking the medication before meals, the client can experience enhanced muscle function during mealtime, which is especially important for managing the symptoms of myasthenia gravis. Choices A, C, and D are incorrect. Taking the medication with food may decrease its effectiveness, avoiding dairy products is not necessary, and taking the medication at bedtime does not coincide with the optimal timing for enhancing muscle function during meals.
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