ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is assessing a client with suspected myocardial infarction. Which finding should the nurse report to the provider?
- A. Pain radiating to the left arm
- B. Pain relieved by rest
- C. Pain worsened with breathing
- D. Pain relieved by antacids
Correct answer: A
Rationale: The correct answer is A: Pain radiating to the left arm. This is a classic symptom of myocardial infarction and indicates possible heart involvement. Reporting this finding to the provider is crucial for prompt evaluation and intervention. Choices B, C, and D are incorrect. Pain relieved by rest, pain worsened with breathing, and pain relieved by antacids are not typical symptoms of myocardial infarction. These findings do not raise the same level of concern as pain radiating to the left arm and are less indicative of cardiac involvement.
2. A nurse is caring for a client who sprained his ankle 12 hours ago. Which of the following provider prescriptions should the nurse question?
- A. Elevate the affected extremity on two pillows
- B. Apply heat to the affected extremity for 45 minutes
- C. Wrap the extremity with a compression dressing
- D. Assess sensation, movement, and pulse every 4 hours
Correct answer: B
Rationale: The nurse should question the prescription to apply heat to the affected extremity for 45 minutes. Heat should not be applied in the first 48 hours after an acute injury, as it can increase swelling. Cold therapy is more appropriate initially. Choices A, C, and D are appropriate actions in the care of a client with a sprained ankle. Elevating the affected extremity helps reduce swelling, wrapping it with a compression dressing provides support, and assessing sensation, movement, and pulse every 4 hours is important to monitor for complications.
3. A healthcare professional is assessing a client for signs of dehydration. Which of the following findings should the healthcare professional look for?
- A. Edema
- B. Dry mucous membranes
- C. Weight gain
- D. Increased urination
Correct answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration. In dehydration, the body loses more water than it takes in, leading to dryness of mucous membranes like the mouth and throat. Edema (choice A) is swelling caused by excess fluid trapped in the body's tissues, which is not a typical sign of dehydration. Weight gain (choice C) is also not a common sign of dehydration; in fact, dehydration usually leads to weight loss. Increased urination (choice D) is more indicative of conditions like diabetes or diuretic use, not dehydration.
4. A nurse is caring for a client prescribed hydroxychloroquine. Which of the following should the nurse monitor?
- A. Liver function tests
- B. Eye exams
- C. Blood glucose levels
- D. Complete blood count
Correct answer: B
Rationale: The correct answer is B: Eye exams. Hydroxychloroquine can cause retinal damage, making it essential for the nurse to monitor the client's eyes regularly for any changes. Monitoring liver function tests (choice A), blood glucose levels (choice C), or complete blood count (choice D) are not directly associated with the potential side effects of hydroxychloroquine.
5. A nurse is teaching a client about the use of aspirin. Which of the following should be included?
- A. It can cause drowsiness
- B. It should be taken with food
- C. Monitor for signs of bleeding
- D. It is safe during pregnancy
Correct answer: C
Rationale: The correct answer is C: 'Monitor for signs of bleeding.' Aspirin is known to increase the risk of bleeding, so clients should be monitored for this potential side effect. Choice A is incorrect because aspirin is not typically associated with causing drowsiness. Choice B is not a specific consideration for aspirin use; it is not necessary to take it with food. Choice D is incorrect because aspirin is not considered safe during pregnancy and should be avoided, especially in the third trimester, as it may cause complications for the mother and the baby.
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