ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A nurse is caring for a client prescribed hydroxychloroquine. Which of the following should the nurse monitor?
- A. Liver function tests
- B. Eye exams
- C. Blood glucose levels
- D. Complete blood count
Correct answer: B
Rationale: The correct answer is B: Eye exams. Hydroxychloroquine can cause retinal damage, making it essential for the nurse to monitor the client's eyes regularly for any changes. Monitoring liver function tests (choice A), blood glucose levels (choice C), or complete blood count (choice D) are not directly associated with the potential side effects of hydroxychloroquine.
2. A client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery should discuss concerns with the surgeon to obtain informed answers. Which statement should the nurse make?
- A. It's normal to feel unsure; the surgery will be beneficial
- B. You can cancel surgery any time without any consequences
- C. I'll inform the surgeon to answer your questions before surgery
- D. We can reschedule surgery for another day
Correct answer: C
Rationale: The correct answer is C because the nurse should facilitate communication between the client and the surgeon to address any doubts and provide necessary information. Choice A may invalidate the client's concerns and might not address the root of the issue. Choice B oversimplifies the situation and might not consider the potential consequences of canceling surgery. Choice D, while offering an alternative, does not address the client's doubts about the surgery.
3. A client receiving oxytocin IV for labor augmentation is experiencing contractions every 45 seconds. What action should the nurse take?
- A. Discontinue the oxytocin infusion
- B. Increase the oxytocin infusion
- C. Decrease the oxytocin infusion
- D. Maintain the oxytocin infusion
Correct answer: A
Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. Contractions occurring every 45 seconds indicate uterine hyperstimulation, which can pose risks to both the client and the fetus. By stopping the oxytocin infusion, the nurse can help prevent further complications. Choices B, C, and D are incorrect because increasing, decreasing, or maintaining the oxytocin infusion can exacerbate the uterine hyperstimulation and increase the risks associated with it.
4. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?
- A. I should apply clean dressings over blood-saturated dressings and hold pressure.
- B. I will rinse the wound with hot water to cleanse it.
- C. I can remove the dressing once the bleeding stops.
- D. I should apply antibiotic ointment directly to the wound.
Correct answer: A
Rationale: The correct answer is A because applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue, aiding in the clotting process and controlling bleeding. Choice B is incorrect as rinsing a wound with hot water can cause further tissue damage. Choice C is incorrect as the dressing should not be removed once applied as it can disrupt the formation of a clot. Choice D is incorrect as antibiotic ointment should not be applied directly to the wound during initial first aid.
5. A nurse is caring for a client who has a prescription for enalapril. The nurse should monitor the client for which of the following adverse effects of this medication?
- A. Bradycardia
- B. Hyperkalemia
- C. Hyperglycemia
- D. Tinnitus
Correct answer: B
Rationale: The correct answer is B: Hyperkalemia. Enalapril, an ACE inhibitor, can lead to hyperkalemia by reducing aldosterone levels, which results in potassium retention. Bradycardia (Choice A) is not a common adverse effect of enalapril. Hyperglycemia (Choice C) and tinnitus (Choice D) are also not typically associated with enalapril use.
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