ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A healthcare professional is assessing a client with deep vein thrombosis (DVT). Which of the following interventions should the healthcare professional include in the plan of care?
- A. Apply ice packs to the affected extremity.
- B. Encourage ambulation every hour.
- C. Elevate the affected leg when in bed.
- D. Massage the affected area to improve circulation.
Correct answer: C
Rationale: Elevating the affected leg is a crucial intervention in the care of a client with deep vein thrombosis (DVT). This position helps reduce swelling and promotes venous return, which can alleviate symptoms associated with DVT. Applying ice packs (Choice A) may worsen the condition by causing vasoconstriction. Encouraging ambulation (Choice B) can dislodge the clot and lead to fatal complications. Massaging the affected area (Choice D) can also dislodge the clot and is contraindicated in DVT.
2. A client with ulcerative colitis has a new prescription for sulfasalazine. What adverse effect should the client monitor for according to the nurse?
- A. Jaundice
- B. Constipation
- C. Oral candidiasis
- D. Sedation
Correct answer: A
Rationale: The correct answer is A: Jaundice. Sulfasalazine can lead to liver toxicity, making it essential to monitor for jaundice, a sign of liver dysfunction. Choices B, C, and D are incorrect because constipation, oral candidiasis, and sedation are not commonly associated with sulfasalazine use.
3. A nurse working in a mobile health clinic is assessing a migrant farm worker. What finding should the nurse identify as a priority?
- A. Report of fatigue and fever
- B. Report of muscle twitching and skin rash
- C. Report of blurred vision
- D. Report of nasal congestion
Correct answer: B
Rationale: Muscle twitching and a skin rash may indicate exposure to pesticides, which requires immediate intervention due to potential toxicity. Fatigue and fever (Choice A) are non-specific symptoms that may indicate various conditions but do not directly indicate pesticide exposure. Blurred vision (Choice C) and nasal congestion (Choice D) are also non-specific symptoms and are less likely to be related to pesticide exposure compared to muscle twitching and a skin rash.
4. A nurse is teaching a client about the use of clopidogrel. Which of the following should be included?
- A. It is an anticoagulant
- B. Monitor for signs of bleeding
- C. It can be stopped abruptly
- D. Avoid foods rich in vitamin K
Correct answer: B
Rationale: The correct answer is B: 'Monitor for signs of bleeding.' Clopidogrel is an antiplatelet medication, not an anticoagulant. Clients taking clopidogrel should be monitored for signs of bleeding due to its antiplatelet effects. Choice A is incorrect because clopidogrel is not an anticoagulant. Choice C is incorrect as clopidogrel should not be stopped abruptly but as directed by a healthcare provider. Choice D is irrelevant since foods rich in vitamin K are more of a concern with anticoagulant medications like warfarin, not antiplatelet medications like clopidogrel.
5. A client with diabetes mellitus is receiving education on foot care. Which of the following instructions should the nurse include?
- A. Apply lotion between the toes.
- B. Cut toenails straight across.
- C. Use a heating pad to warm the feet.
- D. Soak feet in warm water daily.
Correct answer: B
Rationale: The correct answer is B: Cut toenails straight across. This instruction is vital for clients with diabetes as it helps prevent ingrown toenails and infections, reducing the risk of foot ulcers. Applying lotion between the toes (choice A) should be avoided as it can create a moist environment prone to fungal infections. Using a heating pad (choice C) can lead to burns or injuries due to reduced sensation common in diabetes. Soaking feet in warm water daily (choice D) can also increase the risk of skin breakdown and should be avoided.
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