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. A client is being educated about using an intrauterine device (IUD) for contraception. Which of the following client statements indicate an understanding of the teaching?
- A. I will need to have the IUD replaced each year.
- B. I will need to apply a spermicide prior to intercourse.
- C. I should expect my periods to stop while I have the IUD.
- D. I should check for the string each month after menstruation.
Correct answer: D
Rationale: The correct answer is D because the client should check for the string each month after menstruation to ensure the IUD is in place. This practice helps in identifying any displacement of the IUD. Choices A, B, and C are incorrect. A is incorrect because IUDs have different durations depending on the type, not all require yearly replacement. B is incorrect because IUDs do not require spermicide for effectiveness. C is incorrect because while some individuals may experience changes in their menstrual patterns, it is not guaranteed that periods will stop while using an IUD.
3. A nurse is caring for a newborn immediately following birth. What should the nurse do first?
- A. Instill erythromycin ophthalmic ointment
- B. Place identification bracelets on the newborn
- C. Weigh the newborn
- D. Dry the newborn
Correct answer: D
Rationale: Drying the newborn is the first priority to prevent heat loss, which can occur rapidly in newborns due to their large surface area and lack of body fat. This helps maintain the newborn's body temperature and prevent hypothermia. Instilling erythromycin ophthalmic ointment, placing identification bracelets, and weighing the newborn can be important steps but should come after ensuring the newborn is dried to maintain their body temperature.
4. A client has developed a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Administer oxygen
- B. Prepare the client for a thoracentesis
- C. Elevate the client’s lower extremities
- D. Administer anticoagulant therapy
Correct answer: A
Rationale: Administering oxygen is the priority intervention for a client with a pulmonary embolism. Pulmonary embolism can lead to impaired gas exchange, causing hypoxemia. Administering oxygen helps to maintain adequate oxygenation levels. Thoracentesis is not indicated for a pulmonary embolism, as it is a procedure to remove fluid or air from the pleural space, not a treatment for embolism. Elevating the client's lower extremities is not a priority in the management of a pulmonary embolism. Administering anticoagulant therapy is important in the treatment of pulmonary embolism to prevent further clot formation, but it is not the first intervention. Oxygen administration takes precedence to address the immediate oxygenation needs of the client.
5. A client has been prescribed enoxaparin. Which of the following instructions should the nurse provide regarding self-administration?
- A. Pinch the skin and inject at a 45-degree angle
- B. Massage the injection site after administering
- C. Administer at a 90-degree angle
- D. Avoid rotating injection sites
Correct answer: A
Rationale: The correct answer is to pinch the skin and inject at a 45-degree angle when administering enoxaparin. This technique helps ensure proper administration of the medication. Massaging the injection site after administering is unnecessary and could increase the risk of bleeding. Administering at a 90-degree angle is not recommended for enoxaparin injections. Rotating injection sites is important to prevent tissue damage and irritation.
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