ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?
- A. Tidaling with spontaneous respirations
- B. Drainage collection chamber is 1/3 full
- C. 1 cm of water present in the water seal chamber
- D. Suction chamber pressure of -20 cm H2O
Correct answer: C
Rationale: The correct answer is C. There should be 2 cm of water in the water seal chamber of the chest tube system. A level of 1 cm may indicate a leak or compromised functionality that requires intervention. Choices A, B, and D are not findings that necessarily require immediate intervention. Tidaling with spontaneous respirations is an expected finding, the drainage collection chamber being 1/3 full is within normal limits, and a suction chamber pressure of -20 cm H2O indicates appropriate suction for chest drainage.
2. A nurse is educating a patient about their new prescription for a statin medication. What should the nurse advise the patient to avoid while taking this medication?
- A. Drinking grapefruit juice
- B. Consuming high-protein meals
- C. Exercising regularly
- D. Taking the medication in the morning
Correct answer: A
Rationale: The correct answer is A: Drinking grapefruit juice. Grapefruit juice can increase the risk of statin toxicity by interfering with the enzyme that metabolizes statin medications, leading to higher drug levels in the body. This interaction can potentially cause adverse effects. Therefore, patients should be advised to avoid consuming grapefruit juice while taking statins. Choices B, C, and D are incorrect. Consuming high-protein meals, exercising regularly, and taking the medication in the morning are not contraindicated while on statin therapy. In fact, following a healthy diet, engaging in physical activity, and taking the medication at a consistent time each day can be beneficial for patients prescribed statins.
3. A healthcare provider is providing dietary teaching to a client who has chronic kidney disease. Which of the following food choices should the healthcare provider recommend?
- A. A baked potato
- B. A chicken breast
- C. A banana
- D. A cup of orange juice
Correct answer: B
Rationale: The correct answer is B: A chicken breast. Chicken breast is low in potassium, making it a safe option for clients with chronic kidney disease who need to limit their potassium intake. Foods like bananas and orange juice are high in potassium, which should be avoided or limited by individuals with chronic kidney disease to prevent further kidney damage.
4. A healthcare provider is caring for four clients. Which of the following tasks can the healthcare provider delegate to an assistive personnel?
- A. Perform chest compressions during cardiac resuscitation
- B. Perform a dressing change for a new amputee
- C. Assess the effectiveness of antiemetic medication
- D. Provide discharge instructions
Correct answer: A
Rationale: Performing chest compressions during cardiac resuscitation is a critical life-saving intervention that can be delegated to an assistive personnel during an emergency. This task requires immediate action and basic training, making it appropriate for delegation. Performing a dressing change for a new amputee involves specialized knowledge and skills, typically performed by licensed healthcare providers. Assessing the effectiveness of medication requires critical thinking and decision-making skills that are within the scope of a licensed healthcare provider. Providing discharge instructions involves educating the patient on post-discharge care and follow-up, which is typically done by a healthcare provider to ensure clear communication and understanding.
5. A nurse is caring for four clients. Which of the following client data should the nurse report to the provider?
- A. Client who has pleurisy and reports pain of 6 on a scale of 0 to 10
- B. Client with 110 mL of serosanguineous fluid from a Jackson Pratt drain within the first 24 hours after surgery
- C. Client who is 4 hours postoperative and has a heart rate of 98 bpm
- D. Client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3
Correct answer: D
Rationale: An absolute neutrophil count of 75/mm3 indicates severe neutropenia, which puts the client at high risk of infection and requires immediate intervention. Neutropenia increases the susceptibility to infections due to a significant decrease in neutrophils, which are essential for fighting off bacteria and other pathogens. Reporting this critical lab value promptly to the provider is essential to ensure appropriate interventions are initiated to prevent life-threatening infections. Choices A, B, and C do not present immediate life-threatening conditions that require urgent reporting to the provider.
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