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. The nurse is administering sevelamer (RenaGel) during lunch to a client with end-stage renal disease (ESRD). The client asks the nurse to bring the medication later. The nurse should describe which action of RenaGel as an explanation for taking it with meals?
- A. Prevents indigestion associated with the ingestion of spicy foods.
- B. Binds with phosphorus in foods and prevents absorption.
- C. Promotes stomach emptying and prevents gastric reflux.
- D. Buffers hydrochloric acid and prevents gastric erosion.
Correct answer: B
Rationale: Sevelamer (RenaGel) binds with phosphorus in foods to prevent its absorption, which is why it should be taken with meals. By taking RenaGel with meals, it can effectively bind with phosphorus from food, reducing the amount of phosphorus absorbed by the body, thus helping to manage hyperphosphatemia in clients with ESRD. Choices A, C, and D are incorrect because RenaGel's primary action is to bind with phosphorus in foods, not related to preventing indigestion, promoting stomach emptying, or buffering hydrochloric acid.
3. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor to assess the effectiveness of the medication?
- A. Activated partial thromboplastin time (aPTT)
- B. Prothrombin time (PT) and international normalized ratio (INR)
- C. Platelet count
- D. Erythrocyte sedimentation rate (ESR)
Correct answer: B
Rationale: Prothrombin time (PT) and international normalized ratio (INR) are the laboratory values used to monitor the effectiveness of warfarin therapy. These values help ensure that the client is within the therapeutic range for anticoagulation. PT measures the time it takes for blood to clot, while INR standardizes PT results to minimize variations between laboratories. Monitoring these values is crucial to prevent complications such as bleeding or clot formation. Activated partial thromboplastin time (aPTT) (Choice A) is more commonly used to monitor heparin therapy. Platelet count (Choice C) assesses the number of platelets in the blood and is not specific to warfarin therapy. Erythrocyte sedimentation rate (ESR) (Choice D) is a non-specific marker of inflammation and is not used to monitor the effectiveness of warfarin therapy.
4. Which of the following is an early sign that suctioning is required for a client with a tracheostomy?
- A. Bradycardia
- B. Irritability
- C. Confusion
- D. Hypotension
Correct answer: B
Rationale: Irritability is an early sign that suctioning is necessary to clear the airway in a client with a tracheostomy. When secretions build up in the tracheostomy tube, the client may become irritable due to the discomfort and the compromised airway. Bradycardia, confusion, and hypotension are not typically early signs that suctioning is required. Bradycardia may occur if the airway becomes severely compromised, confusion may be a late sign of hypoxia, and hypotension is not directly related to the need for suctioning in a client with a tracheostomy.
5. Which of the following is an abnormal finding when assessing the abdomen of a newborn?
- A. The umbilical cord has two arteries and one vein.
- B. The presence of green vomit.
- C. The liver is palpable 1 to 2 cm below the costal margin.
- D. The abdomen is soft and nondistended.
Correct answer: B
Rationale: The correct answer is B. The presence of green vomit in a newborn is an abnormal finding and indicates a possible intestinal obstruction. This finding requires immediate attention and further investigation. Choices A, C, and D are normal findings in a newborn's abdomen assessment. A newborn typically has an umbilical cord with two arteries and one vein, a liver that may be palpable 1 to 2 cm below the costal margin due to its normal size in a neonate, and a soft, nondistended abdomen as expected in healthy newborns.
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