ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A nurse is caring for a client receiving corticosteroids. Which of the following should the nurse monitor?
- A. Blood glucose levels
- B. Blood pressure
- C. Serum potassium levels
- D. Both A and B
Correct answer: D
Rationale: When a client is receiving corticosteroids, the nurse should monitor both blood glucose levels and blood pressure. Corticosteroids can elevate blood glucose levels, leading to hyperglycemia, and may cause hypertension. Monitoring these parameters is essential to detect and address any potential adverse effects promptly. While monitoring serum potassium levels is important in some situations, it is not a primary concern when caring for a client receiving corticosteroids. Therefore, choices A and B are the most appropriate options for monitoring in this scenario, making option D the correct answer.
2. What are the nursing interventions for a patient with fluid volume overload?
- A. Restrict fluid intake
- B. Monitor intake and output
- C. Administer diuretics as prescribed
- D. Elevate the head of the bed
Correct answer: A
Rationale: The correct nursing intervention for a patient with fluid volume overload is to restrict fluid intake. This helps to prevent further fluid accumulation in the body. Monitoring intake and output (choice B) is important to assess the patient's fluid balance but is not a direct intervention to address fluid volume overload. Administering diuretics as prescribed (choice C) is a medical intervention that may be ordered by a healthcare provider but should not be assumed as a nursing intervention without a prescription. Elevating the head of the bed (choice D) is a measure commonly used for patients with respiratory distress or to prevent aspiration but is not a direct intervention for fluid volume overload.
3. A client with left-leg weakness is learning to use a cane. Which teaching point is most appropriate?
- A. Use the cane on the weaker side of the body
- B. Maintain two points of support on the ground at all times
- C. Advance the cane 30 to 45 cm with each step
- D. Advance the cane and the strong leg simultaneously
Correct answer: B
Rationale: The correct teaching point is to maintain two points of support on the ground at all times when using a cane. This ensures stability and helps distribute weight evenly. Choice A is incorrect because the cane should be used on the stronger side of the body to provide support to the weaker leg. Choice C is incorrect as advancing the cane too far with each step can lead to imbalance. Choice D is incorrect as advancing the cane and the strong leg simultaneously may not provide adequate support for the weaker leg.
4. What is the proper depth of chest compressions for a 9-month-old infant?
- A. 1/3 the diameter of the chest or about 1 1/2 inches.
- B. 1/4 the diameter of the chest or about 1 inch.
- C. 1/2 the diameter of the chest or about 2 inches.
- D. 1/3 the diameter of the chest or about 3/4 inch.
Correct answer: A
Rationale: When performing chest compressions on a 9-month-old infant, the proper depth is 1/3 the diameter of the chest, which equates to approximately 1 1/2 inches. This depth is crucial for effective cardiopulmonary resuscitation (CPR) in infants. Choice B, which suggests 1/4 the diameter of the chest or about 1 inch, is incorrect as it does not provide the recommended depth for infants. Choice C, stating 1/2 the diameter of the chest or about 2 inches, is too deep and may cause harm to the infant. Choice D, mentioning 1/3 the diameter of the chest or about 3/4 inch, is also incorrect as it underestimates the required depth for effective chest compressions on a 9-month-old infant.
5. A nurse is preparing to administer IV furosemide. Which of the following should the nurse monitor for during the infusion?
- A. Increased urinary output
- B. Ototoxicity
- C. Hypokalemia
- D. Hypoglycemia
Correct answer: C
Rationale: The correct answer is C: Hypokalemia. Furosemide is a loop diuretic that works by increasing the excretion of water and electrolytes, particularly potassium. Therefore, the nurse should monitor for hypokalemia, as low potassium levels can lead to various complications such as cardiac dysrhythmias. Choice A, increased urinary output, is an expected effect of furosemide due to its diuretic action but is not a side effect needing monitoring. Ototoxicity (Choice B) is a potential adverse effect of other medications like aminoglycoside antibiotics, not furosemide. Hypoglycemia (Choice D) is not a common side effect associated with furosemide administration.
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