ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A healthcare provider is assessing a client who has severe dehydration. Which finding indicates effective treatment?
- A. Sunken anterior fontanel
- B. Tenting skin turgor
- C. Flat anterior fontanel
- D. Hyperpnea
Correct answer: C
Rationale: A flat anterior fontanel indicates effective treatment for dehydration in infants. Dehydration often causes sunken fontanels, so when the anterior fontanel becomes flat, it suggests that rehydration has occurred. Sunken anterior fontanel (Choice A) is a sign of dehydration, not effective treatment. Tenting skin turgor (Choice B) is also a sign of dehydration, indicating poor skin turgor. Hyperpnea (Choice D) is increased depth and rate of breathing and is not directly related to the hydration status of the client.
2. A client is being educated by a nurse on nutritional intake. Which of the following should the nurse include in the teaching?
- A. Carbohydrates should be at least 45% of your caloric intake
- B. Protein should be at least 55% of your caloric intake
- C. Carbohydrates should be at least 30% of your caloric intake
- D. Protein should be at least 60% of your caloric intake
Correct answer: A
Rationale: Carbohydrates should make up 45-65% of daily caloric intake as they are the body’s main source of energy. This aligns with general dietary recommendations. Choice B is incorrect as protein should typically make up about 10-35% of daily caloric intake, not 55%. Choice C is also incorrect, as carbohydrates should ideally be between 45-65%, not 30%. Choice D is incorrect because protein should generally account for around 10-35% of total caloric intake, not 60%.
3. A healthcare professional is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output?
- A. Shivering
- B. Oliguria
- C. Bradypnea
- D. Constricted pupils
Correct answer: B
Rationale: Oliguria (low urine output) is a sign of decreased cardiac output because the kidneys are not being adequately perfused, leading to reduced urine production. Shivering (choice A) is a response to hypothermia, not directly related to cardiac output. Bradypnea (choice C) refers to abnormally slow breathing rate and is not a direct indicator of decreased cardiac output. Constricted pupils (choice D) can be caused by medications or sympathetic nervous system stimulation but are not specific to decreased cardiac output.
4. A client is being taught about the use of levothyroxine. Which of the following should be included?
- A. It should be taken on an empty stomach
- B. Monitor for signs of hyperthyroidism
- C. It is a pain reliever
- D. It should be taken in the morning
Correct answer: B
Rationale: When educating a client about levothyroxine, it is important to emphasize the need to monitor for signs of hyperthyroidism. Levothyroxine should be taken on an empty stomach, preferably in the morning, to maximize its absorption. Choice A is incorrect as it should not be taken with food. Choice C is incorrect as levothyroxine is not a pain reliever. Choice D is incorrect as levothyroxine is usually taken in the morning.
5. A nurse is preparing to assist a provider with the insertion of a nontunneled percutaneous central venous catheter into a client’s subclavian vein. Which of the following actions should the nurse take?
- A. Position the client in a high-Fowler’s position
- B. Place the client in Trendelenburg position
- C. Place a rolled towel under the client’s neck
- D. Assist the client into a side-lying position
Correct answer: B
Rationale: The correct action for the nurse to take when assisting with the insertion of a nontunneled percutaneous central venous catheter into the subclavian vein is to place the client in Trendelenburg position. This position helps distend the veins and reduces the risk of air embolism during the insertion procedure. Option A, positioning the client in a high-Fowler’s position, would not be appropriate as it does not facilitate venous distention. Option C, placing a rolled towel under the client’s neck, is not directly related to the procedure and does not serve a specific purpose in this context. Option D, assisting the client into a side-lying position, is also not the correct choice as Trendelenburg position is preferred for this procedure to aid in vein distention.
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