ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A nurse is caring for a client prescribed sildenafil for erectile dysfunction. Which of the following should the nurse monitor?
- A. Blood pressure
- B. Heart rate
- C. Temperature
- D. Respiratory rate
Correct answer: A
Rationale: The correct answer is A: Blood pressure. Sildenafil, a medication for erectile dysfunction, can cause changes in blood pressure. The nurse should monitor for hypotension as a potential side effect. Monitoring heart rate (choice B) is not a priority when administering sildenafil unless there are pre-existing heart conditions. Temperature (choice C) and respiratory rate (choice D) are typically not directly affected by sildenafil administration, making them less relevant for monitoring in this case.
2. A healthcare provider is reviewing a client’s care plan. Which of the following goals is most appropriate?
- A. Client will inject insulin twice daily
- B. Client will keep appointments with the healthcare provider for 6 months
- C. Client's A1c will be 5% within one year
- D. Client's blood glucose will stay between 60-120 mg/dL
Correct answer: C
Rationale: The correct answer is C. A1c is a key indicator of long-term diabetes management, reflecting average blood sugar levels over the past 2-3 months. Achieving a target A1c of 5% indicates good control of blood sugar levels and reduces the risk of diabetes-related complications. Choices A, B, and D are not as appropriate as they focus on short-term tasks or individual blood glucose readings, rather than long-term management and outcomes.
3. A client receiving IV moderate (conscious) sedation with midazolam has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse?
- A. Place the client in a prone position
- B. Implement positive pressure ventilation
- C. Perform nasopharyngeal suctioning
- D. Administer flumazenil
Correct answer: D
Rationale: In this scenario, the client is showing signs of respiratory depression and central nervous system depression due to midazolam sedation. Administering flumazenil is the correct action as it is the antidote for midazolam, a benzodiazepine, and can reverse the sedative effects to restore respiratory function. Placing the client in a prone position (choice A) may worsen respiratory compromise. Implementing positive pressure ventilation (choice B) is not the first-line intervention for sedation-related respiratory depression. Performing nasopharyngeal suctioning (choice C) is not indicated as there are no signs of airway obstruction requiring suctioning.
4. A healthcare professional is assessing a client with heart failure. Which of the following signs should the healthcare professional monitor for?
- A. Peripheral edema
- B. Tachycardia
- C. Bradycardia
- D. Hypotension
Correct answer: A
Rationale: In heart failure, the accumulation of fluid can lead to peripheral edema, which is swelling in the extremities. This is a common sign that healthcare professionals should monitor for. While tachycardia (increased heart rate), bradycardia (decreased heart rate), and hypotension (low blood pressure) can also occur in heart failure, they are not the primary signs typically associated with this condition. Therefore, peripheral edema is the most relevant sign to monitor in this case.
5. A client has been prescribed ferrous sulfate. Which instruction should the nurse include?
- A. Take with meals
- B. Take with a glass of orange juice
- C. Take at bedtime
- D. Take with milk
Correct answer: B
Rationale: The correct instruction for a client prescribed ferrous sulfate is to take it with a glass of orange juice. Vitamin C, found in orange juice, enhances the absorption of iron, making it more effective. Taking ferrous sulfate with meals, at bedtime, or with milk can decrease its absorption and effectiveness, so these options are incorrect.
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