ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A nurse is caring for a client prescribed prednisone. Which of the following should the nurse monitor?
- A. Blood glucose levels
- B. Serum potassium levels
- C. Liver function tests
- D. Heart rate
Correct answer: A
Rationale: Corrected Rationale: Prednisone is known to cause hyperglycemia by increasing blood glucose levels. Monitoring blood glucose levels is crucial to detect and manage any potential hyperglycemic effects of prednisone. While prednisone can also affect serum potassium levels and liver function, the priority monitoring parameter in this case is blood glucose levels. Monitoring heart rate is not directly associated with prednisone administration, making it a less relevant parameter to monitor in this scenario.
2. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day
- B. Initiate seizure precautions for the client
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr
- D. Encourage the client to ambulate twice per day
Correct answer: B
Rationale: The correct action for the nurse to take is to initiate seizure precautions for the client. Severe preeclampsia increases the risk of seizures (eclampsia), making it crucial to prioritize the safety of the client. Restricting protein intake (Choice A) is not the priority in this situation as seizure prevention takes precedence. While maintaining hydration is essential, starting an infusion of 0.9% sodium chloride (Choice C) is not the initial action needed for seizure prevention. Encouraging the client to ambulate (Choice D) may not be safe or appropriate considering the severity of preeclampsia and the risk of seizures.
3. While caring for a client receiving nitroglycerin for chest pain, which of the following side effects should the nurse monitor for?
- A. Hypotension
- B. Tachycardia
- C. Bradycardia
- D. Hyperglycemia
Correct answer: A
Rationale: Corrected Rationale: Nitroglycerin is known to cause hypotension due to its vasodilating effect, which can lead to low blood pressure. Therefore, the nurse should closely monitor the client for signs of hypotension such as dizziness, light-headedness, or weakness. Tachycardia (increased heart rate), bradycardia (decreased heart rate), and hyperglycemia (high blood sugar) are not typically associated with nitroglycerin use and are less likely to be side effects that the nurse needs to monitor for in this scenario.
4. A client who is being admitted for induction of labor is receiving teaching about newborn safety from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will check the identification badge of anyone who removes my baby from our room.
- B. I should include a photo of my baby along with any public birth announcements on social media.
- C. I will allow my baby to sleep on the bed in my room when I am in the shower.
- D. I should expect the nurses to carry my baby in their arms to the nursery.
Correct answer: A
Rationale: Choice A is the correct answer because the client should verify the identification badge of anyone removing their baby to ensure the infant's safety and prevent abduction. This statement demonstrates an understanding of the importance of strict identification protocols in the hospital setting. Choice B is incorrect because including a photo of the baby in public announcements does not relate to newborn safety teaching. Choice C is incorrect as it is unsafe to allow a baby to sleep on the bed unsupervised. Choice D is incorrect because nurses typically encourage parents to carry their baby to the nursery themselves for bonding and security reasons.
5. A nurse is caring for a client with a new prescription for enoxaparin to prevent DVT. Which of the following is an appropriate action by the nurse?
- A. Expel any air bubbles from the prefilled syringe
- B. Inject the medication in the lateral abdominal wall
- C. Massage the injection site to evenly distribute the medication
- D. Administer NSAIDs for injection site discomfort
Correct answer: B
Rationale: The correct answer is to inject enoxaparin in the lateral abdominal wall. This site is typically recommended for subcutaneous injections of this medication. Expelling air bubbles from prefilled syringes is not necessary and may result in medication loss. Massaging the injection site is contraindicated as it can cause bruising or hematoma formation. Administering NSAIDs for injection site discomfort is unnecessary and not a standard practice.
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