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 home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor. What intervention should the nurse include in the teaching?
- A. Administer antiseizure medications promptly.
- B. Use oral airway devices during seizures.
- C. Pad the side rails of the bed.
- D. Apply restraints during the seizure to prevent injury.
Correct answer: C
Rationale: The correct intervention the nurse should include in the teaching is to pad the side rails of the bed. By padding the side rails, the nurse can help prevent injury if the patient experiences a seizure. Administering antiseizure medications promptly (Choice A) is typically the responsibility of a healthcare provider or according to a prescribed schedule. Using oral airway devices during seizures (Choice B) can pose risks and should be managed by healthcare professionals. Applying restraints during a seizure (Choice D) is not recommended as it can lead to further injury and complications.
3. A nurse is assessing a client who is at risk for falls. Which of the following findings should the nurse recognize as increasing the client's risk of falling?
- A. Normal gait
- B. Recent history of dizziness
- C. 20/20 vision
- D. Takes a multivitamin daily
Correct answer: B
Rationale: The correct answer is B: Recent history of dizziness. A recent history of dizziness significantly increases the risk of falling, as dizziness can impair balance and coordination. Having a normal gait (choice A) and 20/20 vision (choice C) are not factors that directly increase the risk of falling. Taking a multivitamin daily (choice D) does not inherently contribute to an increased risk of falling unless it causes dizziness as a side effect, which is not specified in the question.
4. A nurse is preparing to administer 1 unit of packed RBCs to a client. Which of the following findings should cause the nurse to delay the transfusion?
- A. Blood pressure 140/90 mm Hg
- B. Urine output of 40 mL/hr
- C. Temperature 38.2°C (100.8°F)
- D. Hemoglobin 8 g/dL
Correct answer: C
Rationale: A temperature of 38.2°C (100.8°F) suggests the possibility of an underlying infection or fever, which should be evaluated before proceeding with the transfusion to prevent complications. Elevated temperature can indicate an immune response to incompatible blood components, increasing the risk of a transfusion reaction. The other vital signs and lab results provided are within acceptable ranges for administering packed RBCs, making choices A, B, and D less likely to cause a delay in the transfusion.
5. A client with a new diagnosis of hypertension is being taught about lifestyle modifications by a nurse. What dietary change should the nurse recommend?
- A. Increase sodium intake
- B. Limit alcohol consumption
- C. Eat a high-protein diet
- D. Follow a high-fat diet
Correct answer: B
Rationale: The correct answer is B: Limit alcohol consumption. When managing hypertension, it is crucial to reduce alcohol intake as it can raise blood pressure. High alcohol consumption can also interfere with the effectiveness of antihypertensive medications. Choices A, C, and D are incorrect. Increasing sodium intake (Choice A) is not recommended for hypertension as it can lead to fluid retention and elevated blood pressure. Eating a high-protein diet (Choice C) or following a high-fat diet (Choice D) are also not ideal for managing hypertension, as they can have negative impacts on cardiovascular health.
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