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 nurse is preparing to administer a unit of packed RBCs to a client. Which of the following actions should the nurse take first?
- A. Administer an antihistamine prior to transfusion.
- B. Check the client’s vital signs.
- C. Verify the client’s identification with another nurse.
- D. Prime the IV tubing with normal saline.
Correct answer: C
Rationale: The correct first action the nurse should take when preparing to administer packed RBCs to a client is to verify the client’s identification with another nurse. This is crucial to ensure that the correct blood product is administered to the correct client, minimizing the risk of a transfusion reaction. Administering an antihistamine prior to transfusion (Choice A) is not the first priority and is not a standard practice. While checking the client’s vital signs (Choice B) is important, verifying the client’s identification takes precedence to prevent a critical error. Priming the IV tubing with normal saline (Choice D) is a necessary step in the process but should occur after verifying the client's identity.
3. A healthcare provider is caring for a client with severe preeclampsia. Which of the following medications should the healthcare provider anticipate administering?
- A. Magnesium sulfate
- B. Oxytocin
- C. Misoprostol
- D. Nifedipine
Correct answer: A
Rationale: Magnesium sulfate is the correct answer as it is administered to prevent seizures in clients with severe preeclampsia. It acts as a central nervous system depressant and is the first-line treatment for eclampsia prevention. Oxytocin (Choice B) is used to induce or augment labor, not indicated specifically for preeclampsia. Misoprostol (Choice C) is used for labor induction and postpartum hemorrhage, not typically indicated for preeclampsia. Nifedipine (Choice D) is a calcium channel blocker used for managing hypertension in pregnancy but is not the first-line treatment for preventing seizures in severe preeclampsia.
4. A client with preeclampsia is receiving magnesium sulfate intravenously. What action should the nurse take if the client develops toxicity?
- A. Position the client supine
- B. Prepare an IV bolus of dextrose 5%
- C. Administer calcium gluconate IV
- D. Administer methylergonovine IM
Correct answer: C
Rationale: In cases of magnesium sulfate toxicity, calcium gluconate is the antidote as it helps reverse the effects. Positioning the client supine (Choice A) may not directly address magnesium sulfate toxicity. Administering dextrose 5% (Choice B) is not the correct intervention for magnesium sulfate toxicity. Methylergonovine IM (Choice D) is used to manage postpartum hemorrhage, not magnesium sulfate toxicity.
5. A nurse is teaching about foot care to a client who has diabetes mellitus (DM). What statement indicates understanding?
- A. I should wear my slippers whenever I am out of bed
- B. I can walk barefoot at home
- C. I should apply lotion between my toes
- D. I can soak my feet in warm water
Correct answer: A
Rationale: The correct answer is A. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it protects the feet from injury. Walking barefoot, as mentioned in option B, can increase the risk of cuts, sores, and infections in diabetic patients. Applying lotion between the toes, as stated in option C, can lead to maceration and increase the risk of fungal infections. Similarly, soaking feet in warm water, as mentioned in option D, can cause skin breakdown and should be avoided by diabetic patients.
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