ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. When caring for a client prescribed azithromycin, what should the nurse monitor?
- A. Liver function
- B. Signs of diarrhea
- C. Blood glucose levels
- D. Serum electrolytes
Correct answer: B
Rationale: The correct answer is to monitor signs of diarrhea when a client is prescribed azithromycin. Azithromycin is known to cause gastrointestinal side effects, particularly diarrhea. Monitoring for diarrhea is crucial to assess the client's response to the medication and to prevent complications such as dehydration. Monitoring liver function (choice A), blood glucose levels (choice C), and serum electrolytes (choice D) are not typically indicated specifically for clients prescribed azithromycin unless there are other specific reasons or conditions that warrant such monitoring.
2. A nurse is planning care for a client who has a chest tube. Which of the following actions should the nurse take to ensure proper functioning of the chest tube?
- A. Clamp the chest tube intermittently.
- B. Keep the drainage system below chest level.
- C. Empty the drainage chamber every 4 hours.
- D. Apply sterile gauze around the insertion site daily.
Correct answer: B
Rationale: To ensure proper functioning of a chest tube, the nurse should keep the drainage system below chest level. This position allows for proper drainage by gravity and prevents backflow into the pleural space. Clamping the chest tube intermittently can lead to a buildup of pressure and should be avoided. Emptying the drainage chamber every 4 hours is important but not directly related to maintaining the chest tube's function. Applying sterile gauze around the insertion site daily is essential for infection prevention but does not specifically ensure the proper functioning of the chest tube.
3. A nurse is caring for a client who has a urinary tract infection (UTI) and is prescribed ciprofloxacin. Which of the following client statements indicates a need for further teaching?
- A. I will stop taking the medication when I feel better.
- B. I will avoid caffeine while taking this medication.
- C. I will wear sunscreen when going outside.
- D. I will drink plenty of fluids while on this medication.
Correct answer: A
Rationale: Clients should be instructed to complete the entire course of antibiotics, even if they start feeling better, to prevent antibiotic resistance and recurrence of infection.
4. A nurse is planning care for a client who has a new diagnosis of dysphagia. Which of the following foods should be included when initiating feeding?
- A. Beef broth
- B. Oatmeal
- C. Apple juice
- D. Toast
Correct answer: B
Rationale: Oatmeal is a soft, easy-to-swallow food, making it appropriate for clients with dysphagia, as it minimizes the risk of aspiration compared to liquids or hard foods. Beef broth (Choice A) is a liquid and may pose a risk of aspiration. Apple juice (Choice C) is a liquid and can also be a choking hazard for individuals with dysphagia. Toast (Choice D) is a hard food that may be difficult for a client with dysphagia to swallow safely.
5. A nurse is receiving a report on four clients. Which of the following clients should the nurse assess first?
- A. A client who has an ileal conduit and mucus in the pouch
- B. Client with arteriovenous fistula with additional vibration palpated
- C. A client with chronic kidney disease and cloudy dialysate outflow
- D. A client with transurethral resection of the prostate with red-tinged urine
Correct answer: C
Rationale: The nurse should assess the client with chronic kidney disease and cloudy dialysate outflow first because cloudy dialysate outflow suggests peritonitis, a serious complication of peritoneal dialysis that requires immediate intervention. Assessing and addressing peritonitis promptly is crucial to prevent further complications and ensure the client's safety. Choices A, B, and D present important findings that require attention but are not as urgent as peritonitis, which can quickly escalate and endanger the client's health.
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