ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is assessing a client who reports chest pain. Which of the following findings should cause the nurse to suspect a myocardial infarction?
- A. Pain improves with rest
- B. Pain radiates to the left arm.
- C. Pain worsens with deep breathing.
- D. Pain is relieved by antacids.
Correct answer: B
Rationale: The correct answer is B. Radiating pain, especially to the left arm, is a classic sign of myocardial infarction. Pain that radiates to the left arm indicates cardiac involvement, making it a significant finding. Choices A, C, and D are incorrect because chest pain that improves with rest, worsens with deep breathing, or is relieved by antacids is less likely to be associated with a myocardial infarction.
2. A nurse is assessing four clients for fluid balance. Which of the following clients is exhibiting manifestations of dehydration?
- A. A client who has a urine specific gravity of 1.010.
- B. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr.
- C. A client who has a hematocrit of 45%.
- D. A client who has a temperature of 39°C (102°F).
Correct answer: D
Rationale: The correct answer is D because an elevated temperature is a common manifestation of dehydration. Choices A, B, and C are not indicative of dehydration. A urine specific gravity of 1.010 is within normal range, weight gain suggests fluid overload, and a hematocrit of 45% is also within normal limits and not specifically related to dehydration.
3. A nurse is teaching a client about the use of atorvastatin. Which of the following should be included?
- A. Monitor for muscle pain
- B. It can cause weight gain
- C. It is safe during pregnancy
- D. It is an anticoagulant
Correct answer: A
Rationale: The correct answer is A: 'Monitor for muscle pain.' Atorvastatin can cause muscle pain and liver function abnormalities, so clients should be monitored for these side effects. Choice B is incorrect because atorvastatin is not known to cause weight gain. Choice C is incorrect as atorvastatin is contraindicated during pregnancy due to potential harm to the fetus. Choice D is incorrect because atorvastatin is a statin medication used to lower cholesterol levels, not an anticoagulant.
4. A nurse is checking laboratory results for a client. Which of the following laboratory findings indicates hypervolemia?
- A. Serum sodium 138 mEq/L
- B. Urine specific gravity 1.001
- C. Serum calcium 10 mg/dL
- D. Urine pH 6
Correct answer: B
Rationale: The correct answer is B. A urine specific gravity of 1.001 is low and indicates dilute urine, which is a sign of fluid overload (hypervolemia). Choice A, serum sodium 138 mEq/L, is within the normal range and does not indicate hypervolemia. Choice C, serum calcium 10 mg/dL, is not typically used to diagnose hypervolemia. Choice D, urine pH 6, is also not a specific indicator of hypervolemia.
5. A client is prescribed insulin glargine. Which of the following should the nurse instruct the client to do regarding administration of this medication?
- A. Inject insulin glargine 30 minutes before a meal.
- B. Shake the insulin vial before administration.
- C. Administer insulin glargine once daily at bedtime.
- D. Take insulin glargine with short-acting insulin.
Correct answer: C
Rationale: The correct answer is C: Administer insulin glargine once daily at bedtime. Insulin glargine is a long-acting insulin that provides a basal level of insulin throughout the day. It should be given at the same time each day, usually at bedtime, to maintain a consistent blood sugar level. Choices A, B, and D are incorrect. Injecting insulin glargine before a meal (Choice A) is not necessary as it is a long-acting insulin. Shaking the insulin vial (Choice B) is not recommended as it may cause bubbles to form, affecting the accuracy of the dose. Taking insulin glargine with short-acting insulin (Choice D) is not a typical practice as insulin glargine is used for basal insulin coverage.
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