ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A nurse is caring for a client prescribed clopidogrel. Which of the following should the nurse monitor?
- A. Liver function tests
- B. Blood pressure
- C. Potassium levels
- D. Respiratory rate
Correct answer: A
Rationale: Corrected Rationale: Clopidogrel is an antiplatelet medication, so the nurse should monitor for signs of bleeding and liver function tests due to potential liver effects. Monitoring liver function tests is essential to detect any adverse effects on the liver because clopidogrel can cause hepatotoxicity. While monitoring blood pressure, potassium levels, and respiratory rate are important in general patient care, they are not the priority assessments specifically related to clopidogrel use.
2. A nurse is caring for a newborn diagnosed with necrotizing enterocolitis (NEC). Which of the following interventions should the nurse expect to implement?
- A. Withhold oral feedings
- B. Measure abdominal girth
- C. Position the newborn supine
- D. Apply cold compresses to the abdomen
Correct answer: B
Rationale: Measuring abdominal girth is crucial in monitoring for signs of abdominal distension, which is a key indicator of worsening necrotizing enterocolitis (NEC). It helps in assessing the progression of the condition. Positioning the newborn supine, as in choice C, can help relieve pressure on the abdomen but does not directly monitor the condition. Applying cold compresses, as in choice D, is not recommended for NEC as it can constrict blood vessels and potentially worsen the condition. Withholding oral feedings, as in choice A, is also important to rest the bowel and prevent further complications, but measuring abdominal girth is more directly related to monitoring the progression of NEC.
3. A client is prescribed digoxin and has a potassium level of 3.0 mEq/L. Which of the following actions should the nurse take?
- A. Administer digoxin without any modifications
- B. Administer the medication at a lower dose
- C. Monitor serum potassium levels
- D. Discontinue the medication if potassium levels rise
Correct answer: A
Rationale: A potassium level of 3.0 mEq/L indicates hypokalemia, which increases the risk of digoxin toxicity. In this case, the nurse should administer the digoxin without any modifications. Lowering the dose (Choice B) may not be necessary if the potassium level is not critically low. Monitoring serum potassium levels (Choice C) is important but should not delay the administration of digoxin. Discontinuing the medication (Choice D) is not the initial action to take unless the potassium levels become severely low and life-threatening.
4. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a catheter occlusion?
- A. Pain during urination
- B. Bladder distention
- C. Cloudy urine
- D. Blood in the catheter tube
Correct answer: B
Rationale: The correct answer is B: Bladder distention. Bladder distention indicates that the bladder is full and there is impaired elimination, which could be caused by catheter occlusion. Pain during urination (choice A) is not typically associated with catheter occlusion but may indicate a urinary tract infection. Cloudy urine (choice C) can be a sign of infection but is not specific to catheter occlusion. Blood in the catheter tube (choice D) may indicate trauma during catheter insertion but is not a typical finding in catheter occlusion.
5. A nurse is caring for a client who has peptic ulcer disease (PUD) and is prescribed sucralfate. Which of the following instructions should the nurse include in the teaching?
- A. Take sucralfate with an antacid.
- B. Take sucralfate 1 hour before meals.
- C. Take sucralfate with food.
- D. Take sucralfate at bedtime only.
Correct answer: B
Rationale: The correct answer is B. Sucralfate should be taken on an empty stomach, 1 hour before meals. This timing allows sucralfate to form a protective barrier over the ulcer, enhancing healing. Choice A is incorrect because sucralfate should not be taken with an antacid. Choice C is incorrect because sucralfate should not be taken with food. Choice D is incorrect because sucralfate should not be taken at bedtime only; it is best absorbed on an empty stomach.
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