ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?
- A. Dry, cracked lips
- B. Bleeding gums
- C. Foul-smelling breath
- D. Red, open sores in the mouth
Correct answer: D
Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.
2. A client who is at 24 weeks of gestation is being taught about the signs of preterm labor. Which of the following should the nurse include?
- A. Sudden weight loss
- B. Regular contractions
- C. Shortness of breath
- D. Vaginal spotting
Correct answer: B
Rationale: The correct answer is B: Regular contractions. Regular contractions before 37 weeks of gestation are a significant sign of preterm labor. It is essential for clients to be aware of this symptom and report it promptly to their healthcare provider. Choices A, C, and D are incorrect because sudden weight loss, shortness of breath, and vaginal spotting are not typical signs of preterm labor. Teaching clients about the specific signs of preterm labor can help in early detection and intervention, ultimately improving outcomes for both the client and the baby.
3. A nurse is caring for a client who has a nasogastric (NG) tube and is receiving enteral feedings. The client reports feeling nauseated. Which of the following actions should the nurse take first?
- A. Administer an antiemetic.
- B. Check the client’s bowel sounds.
- C. Slow the rate of the feeding.
- D. Place the client in a supine position.
Correct answer: B
Rationale: The correct action for the nurse to take first when a client with a nasogastric tube reports feeling nauseated is to check the client's bowel sounds. This assessment helps the nurse evaluate for possible complications, such as a blockage or decreased gastric motility, that could be causing the nausea. Administering an antiemetic (Choice A) should not be the first action without assessing the underlying cause of the nausea. Slowing the rate of the feeding (Choice C) may be appropriate but is not the priority until further assessment is done. Placing the client in a supine position (Choice D) is not typically indicated for managing nausea in this situation.
4. A patient with chronic kidney disease reports feeling light-headed after taking their medication. What should the nurse instruct the patient to do?
- A. Take the medication with food
- B. Take the medication at bedtime
- C. Stand up slowly to prevent dizziness
- D. Increase fluid intake
Correct answer: C
Rationale: Patients with chronic kidney disease are prone to orthostatic hypotension, which can cause dizziness. To prevent this, the nurse should instruct the patient to stand up slowly. Options A, B, and D do not directly address the issue of orthostatic hypotension and dizziness in this scenario.
5. A client has a new prescription for oxcarbazepine. Which of the following should the nurse monitor?
- A. Liver function
- B. Serum sodium levels
- C. Blood glucose
- D. Heart rate
Correct answer: B
Rationale: The correct answer is B: Serum sodium levels. Oxcarbazepine can lead to hyponatremia, making it crucial to monitor serum sodium levels. Monitoring liver function (choice A) is not typically associated with oxcarbazepine use. Blood glucose (choice C) monitoring is more relevant in medications affecting blood sugar levels. Heart rate (choice D) is not directly impacted by oxcarbazepine.
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