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 professional is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output?
- A. Shivering
- B. Oliguria
- C. Bradypnea
- D. Constricted pupils
Correct answer: B
Rationale: Oliguria (low urine output) is a sign of decreased cardiac output because the kidneys are not being adequately perfused, leading to reduced urine production. Shivering (choice A) is a response to hypothermia, not directly related to cardiac output. Bradypnea (choice C) refers to abnormally slow breathing rate and is not a direct indicator of decreased cardiac output. Constricted pupils (choice D) can be caused by medications or sympathetic nervous system stimulation but are not specific to decreased cardiac output.
3. While providing education about the use of lorazepam, which of the following should be included?
- A. It can cause dependency
- B. It can be taken with alcohol
- C. It has no side effects
- D. It is a stimulant
Correct answer: A
Rationale: The correct answer is A: 'It can cause dependency.' Lorazepam is a benzodiazepine known to cause dependency, so it is crucial for clients to be informed about this potential risk. Choice B is incorrect as combining lorazepam with alcohol can lead to increased sedation and other adverse effects. Choice C is incorrect because lorazepam, like any medication, can have side effects such as drowsiness, dizziness, or confusion. Choice D is also incorrect as lorazepam is a sedative-hypnotic medication, not a stimulant.
4. A nurse is caring for a client prescribed hydromorphone for severe pain. The client's respiratory rate has decreased from 16 breaths per minute to 6. Which of the following medications should the nurse prepare to administer?
- A. Naloxone
- B. Flumazenil
- C. Activated charcoal
- D. Aluminum hydroxide
Correct answer: A
Rationale: Naloxone is the correct answer. Naloxone is the antidote for opioid overdose, including hydromorphone. Opioids can cause respiratory depression, and a significant decrease in respiratory rate from 16 to 6 breaths per minute indicates respiratory compromise. Naloxone should be administered promptly to reverse the effects of the opioid and restore normal respiratory function. Flumazenil (Choice B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (Choice C) is used for gastrointestinal decontamination in cases of overdose with certain substances, but it is not the appropriate intervention for opioid-induced respiratory depression. Aluminum hydroxide (Choice D) is an antacid and has no role in managing opioid overdose or respiratory depression.
5. A healthcare provider is assessing a client who is receiving IV gentamicin three times daily. Which of the following findings indicates that the client is experiencing an adverse effect of this medication?
- A. Hypoglycemia
- B. Proteinuria
- C. Nasal congestion
- D. Visual disturbances
Correct answer: B
Rationale: Corrected Rationale: Gentamicin is known to cause nephrotoxicity as an adverse effect. Proteinuria, which is the presence of excess proteins in the urine, may indicate kidney damage from the medication. Monitoring renal function is crucial in clients receiving gentamicin. Choice A, hypoglycemia, is not a typical adverse effect of gentamicin. Choices C and D, nasal congestion and visual disturbances, are not commonly associated with gentamicin use or its adverse effects.
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