ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A healthcare professional is assessing a client for signs of respiratory distress. Which of the following findings should the healthcare professional look for?
- A. Shallow breathing
- B. Bradycardia
- C. Increased appetite
- D. Warm, dry skin
Correct answer: A
Rationale: Corrected Question: A healthcare professional is assessing a client for signs of respiratory distress. Shallow breathing is a key indicator of respiratory distress, reflecting an inadequate exchange of oxygen and carbon dioxide. Bradycardia (Choice B) refers to a slow heart rate and is not typically a direct sign of respiratory distress. Increased appetite (Choice C) and warm, dry skin (Choice D) are unrelated to respiratory distress. Therefore, the correct answer is A.
2. When caring for a client with a sealed radiation implant, which action should be included in the plan of care?
- A. Remove dirty linens after double bagging them
- B. Wear a dosimeter film badge while in the client’s room
- C. Limit visitors to 1 hour per day
- D. Ensure family members remain at least 3 feet from the client
Correct answer: B
Rationale: The correct answer is to wear a dosimeter film badge while in the client's room. This is crucial for monitoring radiation exposure levels when caring for a client with a sealed radiation implant. Option A is incorrect as removing dirty linens after double bagging them is not directly related to radiation safety. Option C is incorrect as there is no specific guideline to limit visitors to 1 hour per day for clients with sealed radiation implants. Option D is incorrect as the distance of family members from the client is not a primary safety measure when dealing with sealed radiation implants.
3. A nurse is caring for a client who has a nasogastric (NG) tube and is receiving enteral feedings. The client reports feeling nauseated. Which of the following actions should the nurse take first?
- A. Administer an antiemetic.
- B. Check the client’s bowel sounds.
- C. Slow the rate of the feeding.
- D. Place the client in a supine position.
Correct answer: B
Rationale: The correct action for the nurse to take first when a client with a nasogastric tube reports feeling nauseated is to check the client's bowel sounds. This assessment helps the nurse evaluate for possible complications, such as a blockage or decreased gastric motility, that could be causing the nausea. Administering an antiemetic (Choice A) should not be the first action without assessing the underlying cause of the nausea. Slowing the rate of the feeding (Choice C) may be appropriate but is not the priority until further assessment is done. Placing the client in a supine position (Choice D) is not typically indicated for managing nausea in this situation.
4. A nurse is assessing a male adolescent client who has heart failure. Based on the client’s chart, which of the following actions should the nurse plan to take?
- A. Withhold spironolactone
- B. Administer ferrous sulfate
- C. Administer furosemide
- D. Withhold digoxin
Correct answer: C
Rationale: The correct answer is to administer furosemide. Furosemide is a diuretic commonly used in heart failure to manage fluid retention, helping alleviate symptoms like edema and shortness of breath. Withholding spironolactone, a potassium-sparing diuretic, could lead to electrolyte imbalances. Administering ferrous sulfate is used to treat iron deficiency anemia, not heart failure. Withholding digoxin, a medication used in heart failure to improve heart function, can worsen the client's condition.
5. A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?
- A. A client who is able to bear full weight on both lower extremities.
- B. A client who has bilateral leg braces due to paralysis of the lower extremities.
- C. A client who has a right femur fracture with no weight bearing on the affected leg.
- D. A client who has bilateral knee replacements with partial weight bearing on both legs.
Correct answer: C
Rationale: The correct answer is C because a three-point gait is used when the client can bear full weight on one foot and uses crutches and the uninvolved leg to ambulate. Choices A, B, and D are incorrect because they do not meet the criteria for using a three-point gait. Choice A states that the client can bear full weight on both lower extremities, which does not require a three-point gait. Choice B mentions bilateral leg braces due to paralysis, which would not involve using a three-point gait. Choice D describes a client with bilateral knee replacements with partial weight bearing, which also does not align with the use of a three-point gait.
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