ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client 4 hours postoperative following a thyroidectomy. The client reports fullness in the throat. What should the nurse assess for?
- A. Hypocalcemia
- B. Hemorrhage
- C. Hypoxia
- D. Hypothyroidism
Correct answer: B
Rationale: In this scenario, the correct answer is B: Hemorrhage. Fullness in the throat post-thyroidectomy can indicate postoperative bleeding, a critical complication that requires immediate assessment and intervention. Choice A, Hypocalcemia, is incorrect because it does not typically present with fullness in the throat. Choice C, Hypoxia, is not directly related to the symptom described and is not the primary concern in this situation. Choice D, Hypothyroidism, is also incorrect as it is a long-term condition and unlikely to manifest suddenly 4 hours postoperatively with throat fullness.
2. A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50 breaths per minute with periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take?
- A. Administer oxygen
- B. Stimulate the newborn
- C. Initiate positive pressure ventilation
- D. Continue routine monitoring
Correct answer: D
Rationale: A respiratory rate of 50 breaths per minute with occasional periods of apnea lasting less than 15 seconds is normal for a newborn. The nurse should continue routine monitoring unless the apneic periods become prolonged or the newborn shows signs of respiratory distress. Administering oxygen or initiating positive pressure ventilation is not indicated in this scenario as the newborn's respiratory rate and apneic episodes are within normal limits for their age. Stimulating the newborn is also unnecessary since the described parameters fall within the expected range for a 1-hour-old infant.
3. A client with mild persistent asthma is being taught about montelukast by a nurse. Which statement by the client indicates understanding?
- A. I will use this for asthma attacks.
- B. I should take this before exercise.
- C. This medication will decrease swelling and mucus production.
- D. I can stop this medication after 10 days.
Correct answer: C
Rationale: The correct answer is C: 'This medication will decrease swelling and mucus production.' Montelukast is a leukotriene receptor antagonist that works by reducing swelling and mucus production in the airways, helping to manage asthma symptoms in the long term. Choices A, B, and D are incorrect because montelukast is not used for immediate relief during asthma attacks, pre-exercise prophylaxis, or short-term treatment; instead, it is taken regularly for asthma control.
4. A nurse is teaching a client about the use of levetiracetam. Which of the following should be included in the teaching?
- A. It can cause weight loss
- B. Monitor for mood changes
- C. It is an over-the-counter medication
- D. It has no side effects
Correct answer: B
Rationale: The correct answer is B. Levetiracetam can cause mood changes and behavioral side effects, so clients should be monitored for these effects. Choice A is incorrect because levetiracetam is not typically associated with weight loss. Choice C is incorrect as levetiracetam is a prescription medication, not available over the counter. Choice D is incorrect as all medications, including levetiracetam, have potential side effects.
5. A client is being educated by a nurse on nutritional intake. Which of the following should the nurse include in the teaching?
- A. Carbohydrates should be at least 45% of your caloric intake
- B. Protein should be at least 55% of your caloric intake
- C. Carbohydrates should be at least 30% of your caloric intake
- D. Protein should be at least 60% of your caloric intake
Correct answer: A
Rationale: Carbohydrates should make up 45-65% of daily caloric intake as they are the body’s main source of energy. This aligns with general dietary recommendations. Choice B is incorrect as protein should typically make up about 10-35% of daily caloric intake, not 55%. Choice C is also incorrect, as carbohydrates should ideally be between 45-65%, not 30%. Choice D is incorrect because protein should generally account for around 10-35% of total caloric intake, not 60%.
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