ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is assessing a client who has systemic lupus erythematosus (SLE). Which of the following findings should the nurse expect?
- A. Butterfly rash on the face
- B. Weight gain
- C. Joint deformities
- D. Increased hair growth
Correct answer: A
Rationale: The correct answer is A: Butterfly rash on the face. A butterfly-shaped rash across the nose and cheeks is a classic symptom of systemic lupus erythematosus (SLE), an autoimmune disease. Weight gain (Choice B) is not typically associated with SLE. Joint deformities (Choice C) are more commonly seen in conditions like rheumatoid arthritis. Increased hair growth (Choice D) is not a typical finding in SLE.
2. A nurse receives a report on four clients. Which client should the nurse assess first?
- A. A client scheduled for chemotherapy with a hemoglobin of 9 g/dL
- B. A client 24 hours post-TURP with small blood clots in the catheter
- C. A client receiving a blood transfusion who reports low back pain
- D. A client with a new colostomy and a reddish-pink stoma
Correct answer: C
Rationale: The correct answer is C. Low back pain during a blood transfusion is a classic sign of a transfusion reaction, specifically a transfusion-associated circulatory overload (TACO) or hemolytic reaction, both of which require immediate attention to prevent serious complications. Assessing this client first is crucial to ensure prompt intervention. Choices A, B, and D do not indicate immediate life-threatening complications and can be addressed after the client experiencing low back pain during a blood transfusion is stabilized.
3. A nurse is providing discharge instructions to a client after a myocardial infarction. Which of the following should be included?
- A. Resume normal activities immediately
- B. Monitor for chest pain and report any recurrence
- C. Avoid all physical activity for 6 months
- D. Take medications only as needed
Correct answer: B
Rationale: The correct answer is B: 'Monitor for chest pain and report any recurrence.' After a myocardial infarction, it is crucial for clients to be vigilant about any signs of chest pain as it could indicate a recurrent event. Prompt reporting of chest pain can lead to timely intervention, preventing further complications. Choice A is incorrect because resuming normal activities immediately after a heart attack can be dangerous and is not recommended. Choice C is also incorrect as avoiding all physical activity for 6 months is excessive and can lead to deconditioning. Choice D is incorrect as medications prescribed after a myocardial infarction are usually meant to be taken regularly as prescribed, not just as needed.
4. A nurse is caring for a client with a new prescription for furosemide. Which of the following should the nurse monitor?
- A. Serum potassium levels
- B. Liver function
- C. Blood glucose levels
- D. Calcium levels
Correct answer: A
Rationale: Corrected Rationale: When a client is prescribed furosemide, the nurse should monitor serum potassium levels. Furosemide is a loop diuretic that can lead to potassium loss, potentially causing hypokalemia. Monitoring serum potassium levels is crucial to prevent complications such as cardiac dysrhythmias. Choices B, C, and D are incorrect because furosemide primarily affects potassium excretion rather than liver function, blood glucose levels, or calcium levels.
5. A school nurse is providing care for students in an elementary education facility. What intervention by the nurse addresses the primary level of prevention?
- A. Monitor for signs of illness.
- B. Teach students about healthy food choices.
- C. Administer medication to students with chronic conditions.
- D. Monitor immunization compliance.
Correct answer: B
Rationale: The correct answer is B: Teach students about healthy food choices. Teaching healthy habits like proper nutrition is an example of primary prevention because it aims to prevent disease before it occurs. Choice A, monitoring for signs of illness, is more related to secondary prevention (early detection and treatment). Choice C, administering medication to students with chronic conditions, is a form of tertiary prevention (managing existing conditions to prevent complications). Choice D, monitoring immunization compliance, is also a form of primary prevention but focuses on preventing specific infectious diseases through immunization rather than general health promotion.
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