ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A nurse is assessing a client with chronic kidney disease. Which of the following findings should the nurse monitor?
- A. Hypokalemia
- B. Fluid overload
- C. Decreased blood pressure
- D. Increased appetite
Correct answer: B
Rationale: The correct answer is B: Fluid overload. Clients with chronic kidney disease are prone to fluid overload due to impaired kidney function. The kidneys may not effectively regulate fluid balance, leading to fluid retention. Monitoring for signs of fluid overload, such as edema, hypertension, and shortness of breath, is crucial. Choice A, Hypokalemia, is less likely in chronic kidney disease as the kidneys often have difficulty excreting potassium, leading to hyperkalemia. Decreased blood pressure (Choice C) is not a common finding in chronic kidney disease unless complications like volume depletion occur. Increased appetite (Choice D) is not typically associated with chronic kidney disease; in fact, many clients may experience a decreased appetite due to various factors such as uremia and dietary restrictions.
2. A nurse is performing a focused assessment for a client who has dysrhythmias. What indicates ineffective cardiac contractions?
- A. Increased blood pressure
- B. Pulse deficit
- C. Normal heart rate
- D. Elevated oxygen saturation
Correct answer: B
Rationale: The correct answer is B: Pulse deficit. A pulse deficit is a significant finding in clients with dysrhythmias, indicating ineffective cardiac contractions. Pulse deficit occurs when there is a difference between the apical and radial pulses, suggesting that not all heart contractions are strong enough to produce a pulse that can be felt peripherally. Increased blood pressure (choice A) may occur due to various factors and is not a direct indicator of ineffective cardiac contractions. Similarly, a normal heart rate (choice C) and elevated oxygen saturation (choice D) do not specifically point towards ineffective cardiac contractions; they can be present in individuals with dysrhythmias but do not directly indicate ineffective cardiac contractions.
3. To reduce the incidence of sudden infant death syndrome (SIDS), how should the parents position the newborn?
- A. Prone position
- B. Supine position
- C. Side-lying position
- D. Semi-Fowler's position
Correct answer: B
Rationale: The correct answer is B: Supine position. Placing the newborn on their back (supine position) is the safest sleeping position to reduce the risk of sudden infant death syndrome (SIDS). This position helps prevent airway obstruction, which can occur when infants are placed on their stomach (prone position), side (side-lying position), or in a semi-upright position (semi-Fowler's position). The prone position (choice A) is associated with an increased risk of SIDS, making it an unsafe choice. Side-lying position (choice C) and semi-Fowler's position (choice D) also pose risks of airway compromise and are not recommended for sleep positioning to prevent SIDS. Therefore, options A, C, and D are incorrect in this context.
4. A client with lactose intolerance, who has eliminated dairy products from the diet, should increase consumption of which of the following foods?
- A. Spinach
- B. Peanut butter
- C. Ground beef
- D. Carrots
Correct answer: A
Rationale: Spinach is the correct answer because it is a good source of calcium, which is important for clients with lactose intolerance who are not consuming dairy products. Peanut butter, ground beef, and carrots do not provide as much calcium as spinach and are not the best choices for meeting the calcium needs of clients with lactose intolerance.
5. A patient is receiving discharge teaching for esophageal cancer and starting radiation therapy. What instruction should the healthcare provider include?
- A. Remove dye markings after each radiation treatment
- B. Apply a warm compress to the irradiated site
- C. Wear clothing over the area of radiation treatment
- D. Use a washcloth to bathe the treatment area
Correct answer: C
Rationale: The correct instruction for a patient starting radiation therapy for esophageal cancer is to wear clothing over the area of radiation treatment. This helps to prevent irritation and protect the skin. Removing dye markings after each treatment (choice A) is unnecessary and not typically part of the patient's self-care. Applying a warm compress (choice B) can exacerbate skin irritation caused by radiation. Using a washcloth to bathe the treatment area (choice D) can potentially irritate the skin further, making it important to avoid.
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