ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a 7-month-old infant being treated for severe dehydration. Which finding indicates treatment has been effective?
- A. Skin turgor displays tenting
- B. Flat anterior fontanel
- C. Cool, mottled skin
- D. Hyperpnea
Correct answer: B
Rationale: A flat anterior fontanel indicates improved hydration in infants, as dehydration typically causes sunken fontanels.
2. A nurse is reviewing laboratory results for a client receiving chemotherapy. Which result should the nurse report to the provider?
- A. WBC 3,000/mm³
- B. Hemoglobin 12 g/dL
- C. Platelet count 250,000/mm³
- D. Serum sodium 140 mEq/L
Correct answer: A
Rationale: The correct answer is A: WBC 3,000/mm³. A WBC count of 3,000/mm³ indicates neutropenia, which is a condition characterized by a low level of white blood cells, specifically neutrophils. Neutropenia increases the risk of infection and requires immediate medical attention, especially in clients undergoing chemotherapy. Reporting this result to the provider promptly is crucial for further evaluation and intervention. Choices B, C, and D are within normal ranges and do not pose an immediate risk to the client's health. Hemoglobin of 12 g/dL, platelet count of 250,000/mm³, and serum sodium of 140 mEq/L are all normal values and would not typically require immediate reporting unless there are specific concerns related to the individual client's condition.
3. A client receiving opiates for pain management was initially sedated but is no longer sedated after three days. What action should the nurse take?
- A. Initiate additional non-pharmacological pain management techniques.
- B. Notify the provider that a dosage adjustment is needed.
- C. No action is needed at this time.
- D. Contact the provider to request an alternate method of pain management.
Correct answer: C
Rationale: The correct answer is C: No action is needed at this time. Sedation from opiates commonly decreases as the body adjusts to the medication. It is a positive sign that the sedation has resolved, indicating the client is tolerating the current dosage well. Initiating additional non-pharmacological pain management techniques (Choice A) is unnecessary since the current pain management regimen is effective. Notifying the provider for a dosage adjustment (Choice B) is premature and not indicated when the sedation has resolved. Contacting the provider to request an alternate method of pain management (Choice D) is excessive and not warranted in this situation where the client is no longer sedated and the current pain management plan is effective.
4. A postpartum client who delivered a healthy newborn is being assessed by a nurse. Which finding would indicate a complication during the early postpartum period?
- A. Moderate lochia rubra
- B. Bradycardia
- C. Elevated blood pressure
- D. Uterine contraction
Correct answer: C
Rationale: An elevated blood pressure in the postpartum period may indicate the onset of preeclampsia, a serious complication that requires immediate medical attention. Preeclampsia is characterized by high blood pressure, protein in the urine, and sometimes swelling in the hands and face. If left untreated, preeclampsia can lead to serious complications for both the mother and the baby. Therefore, it is crucial for healthcare providers to closely monitor blood pressure levels in postpartum clients to promptly address any signs of preeclampsia. Choices A, B, and D are not indicative of a complication during the early postpartum period. Moderate lochia rubra is a normal finding as it indicates the normal discharge of blood and tissue from the uterus after childbirth. Bradycardia, a slow heart rate, is not typically a concern in the absence of other symptoms or signs of distress. Uterine contractions are essential for involution and are expected in the postpartum period.
5. A client with heart failure is prescribed furosemide (Lasix). The nurse should monitor the client for which potential electrolyte imbalance?
- A. Hyperkalemia
- B. Hypernatremia
- C. Hypokalemia
- D. Hypocalcemia
Correct answer: C
Rationale: When a client with heart failure is prescribed furosemide, the nurse should monitor for hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, which increases the risk of hypokalemia. Hypokalemia can have serious implications such as cardiac dysrhythmias. Therefore, it is essential to closely monitor the client's serum potassium levels while on furosemide to prevent complications. Hyperkalemia (Choice A) is incorrect because furosemide leads to potassium loss, not retention. Hypernatremia (Choice B) is not typically associated with furosemide use. Hypocalcemia (Choice D) is not a common electrolyte imbalance caused by furosemide.
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