ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A client is prescribed furosemide. Which of the following is a potential side effect?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypernatremia
Correct answer: B
Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through urine, causing hypokalemia. Hyperkalemia (choice A) is not a side effect of furosemide. Hyponatremia (choice C) and hypernatremia (choice D) are related to sodium levels rather than potassium, and they are not typically associated with furosemide use.
2. A nurse is assessing a client who has a brainstem injury. The nurse should expect the client to exhibit which of the following findings?
- A. Decerebrate posturing.
- B. Hypervigilance.
- C. Absence of deep tendon reflexes.
- D. Glasgow Coma Scale score of 15.
Correct answer: A
Rationale: The correct answer is A: Decerebrate posturing. Decerebrate posturing is an abnormal body posture characterized by rigid extension of the arms and legs, which indicates severe brainstem injury affecting the midbrain and pons. This posture suggests dysfunction or damage to neural pathways controlling muscle tone. Choice B, hypervigilance, is not typically associated with brainstem injury but rather with increased alertness and arousal. Choice C, absence of deep tendon reflexes, is not a specific finding related to brainstem injury. Choice D, a Glasgow Coma Scale score of 15, indicates a fully awake and alert state, which is not expected in a client with a brainstem injury.
3. In monitoring the effectiveness of warfarin therapy for a client with a history of atrial fibrillation, which laboratory value should the nurse monitor?
- A. Activated partial thromboplastin time (aPTT)
- B. Prothrombin time (PT) and international normalized ratio (INR)
- C. Platelet count
- D. Erythrocyte sedimentation rate (ESR)
Correct answer: B
Rationale: Prothrombin time (PT) and international normalized ratio (INR) are crucial laboratory values to monitor the effectiveness of warfarin therapy in clients with atrial fibrillation. These values help ensure that the client is within the therapeutic range and that the anticoagulant effect of warfarin is appropriate. Monitoring aPTT, platelet count, or ESR is not directly related to assessing the effectiveness of warfarin therapy in these cases.
4. In contrast to the contractions associated with true labor, Braxton-Hicks contractions:
- A. generally follow rupture of the amniotic sac and occur with regularity.
- B. may be intensified by activity and are accompanied by a pink discharge.
- C. do not increase in intensity and are alleviated by a change in position.
- D. consistently become stronger and are not alleviated by changing position.
Correct answer: C
Rationale: Braxton-Hicks contractions are irregular and usually do not increase in intensity. Unlike true labor contractions, they tend to alleviate with a change in position, making option C the correct choice. Choices A, B, and D are incorrect because Braxton-Hicks contractions do not follow rupture of the amniotic sac, are not intensified by activity or accompanied by a pink discharge, and do not consistently become stronger or are not alleviated by changing position.
5. The client has just been diagnosed with Addison's disease. Which clinical manifestation should the nurse expect to find?
- A. Hypertension and hyperglycemia.
- B. Hyperpigmentation and hypotension.
- C. Exophthalmos and tachycardia.
- D. Weight gain and fluid retention.
Correct answer: B
Rationale: Hyperpigmentation and hypotension are classic clinical manifestations of Addison's disease due to decreased cortisol production. Hyperpigmentation occurs due to elevated levels of ACTH, leading to increased melanin synthesis. Hypotension results from aldosterone deficiency, causing sodium loss and volume depletion.
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