ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is assessing a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?
- A. Blood glucose 120 mg/dL
- B. pH 7.32
- C. HCO3 25 mEq/L
- D. PaCO2 48 mm Hg
Correct answer: B
Rationale: The correct answer is B. A pH of 7.32 indicates metabolic acidosis, which is a hallmark of diabetic ketoacidosis (DKA). In DKA, blood glucose levels are typically elevated, bicarbonate levels are often low, and there is a compensatory respiratory response leading to a decrease in PaCO2. Option A is incorrect because a blood glucose level of 120 mg/dL is within the normal range and not indicative of DKA. Option C is incorrect because an HCO3 level of 25 mEq/L is not typically seen in DKA where bicarbonate levels are usually lower. Option D is incorrect because a PaCO2 of 48 mm Hg would not be expected in DKA; it would typically be lower due to compensatory respiratory alkalosis.
2. The nurse formulates a nursing diagnosis of 'High risk for ineffective airway clearance' for a client with myasthenia gravis. What is the most likely etiology for this nursing diagnosis?
- A. Pain when coughing.
- B. Diminished cough effort.
- C. Thick, dry secretions.
- D. Excessive inflammation.
Correct answer: B
Rationale: The correct answer is B: Diminished cough effort. Clients with myasthenia gravis often experience muscle weakness, including respiratory muscles, which can lead to diminished cough effort. This weakness can result in ineffective airway clearance, putting the client at a high risk. Pain when coughing (choice A) is not directly related to the etiology of ineffective airway clearance in myasthenia gravis. While thick, dry secretions (choice C) and excessive inflammation (choice D) can contribute to airway clearance issues, the primary concern in myasthenia gravis is the muscle weakness affecting cough effort.
3. How should a healthcare professional assess a patient with suspected deep vein thrombosis (DVT)?
- A. Monitor for leg pain, swelling, and redness
- B. Check for calf tenderness and administer anticoagulants
- C. Check for discoloration and monitor oxygen saturation
- D. Check for numbness and provide thrombolytic therapy
Correct answer: A
Rationale: Correct Answer: The correct way to assess a patient with suspected deep vein thrombosis (DVT) is to monitor for leg pain, swelling, and redness. These are common clinical manifestations of DVT. Choice B is incorrect because administering anticoagulants should be based on a confirmed diagnosis, not just suspicion. Choice C is incorrect because discoloration and oxygen saturation are not primary indicators of DVT. Choice D is incorrect because numbness is not a typical symptom of DVT, and thrombolytic therapy is not the first-line treatment for suspected DVT.
4. A nurse is assisting with meal planning for a client who has been prescribed a mechanical soft diet. The nurse should instruct the client to avoid which of the following foods?
- A. Applesauce
- B. Mashed potatoes
- C. Orange slices
- D. Soft bread
Correct answer: C
Rationale: The correct answer is C: Orange slices. Orange slices contain membranes that are difficult to swallow, which can pose a risk to clients on a mechanical soft diet. This type of diet is designed for individuals who have difficulty chewing or swallowing. Choices A, B, and D are suitable for a mechanical soft diet as they are soft in texture and easy to chew and swallow.
5. A healthcare provider is reviewing the medical records of a group of older adults (OA). The provider should identify that which of the following is a risk factor that places OA at an increased risk for developing infections?
- A. Improved circulation
- B. Increased immune function
- C. Lowered immune system function
- D. Dehydration
Correct answer: C
Rationale: The correct answer is C: 'Lowered immune system function.' As individuals age, their immune system tends to weaken, making them more susceptible to infections. Choices A, B, and D are incorrect because improved circulation and increased immune function would typically reduce the risk of infections, while dehydration can impact overall health but is not directly related to immune system function in the context of infection risk.
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