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. The nurse instructs the patient about incentive spirometry as part of preoperative teaching. Which phase of the nursing process does this illustrate?
- A. Assessment
- B. Planning
- C. Implementation
- D. Evaluation
Correct answer: C
Rationale: Instructing a patient about incentive spirometry falls under the implementation phase of the nursing process. During this phase, nursing interventions are put into action. Assessment (choice A) involves collecting data about the patient's condition, planning (choice B) involves setting goals and creating a care plan, and evaluation (choice D) involves assessing the outcomes of nursing interventions. Therefore, the correct answer is C, as it reflects the active teaching and intervention part of the process.
3. When teaching a client about the use of trazodone, what should be included?
- A. It can cause sedation
- B. It is a stimulant
- C. It has no side effects
- D. It should be taken with food
Correct answer: A
Rationale: The correct answer is A. Trazodone can cause sedation, so clients should be cautioned about activities requiring alertness, like driving. Choice B is incorrect because trazodone is not a stimulant; it is actually a sedating antidepressant. Choice C is incorrect as all medications have potential side effects. Choice D is not specifically indicated for trazodone; the client should follow the prescribing healthcare provider's instructions regarding food intake.
4. A nurse is caring for a client who has been prescribed methadone. Which of the following client statements indicates a need for further teaching?
- A. I understand methadone slows my breathing.
- B. I understand methadone may cause me to have trouble sleeping.
- C. I will avoid alcohol while I’m taking this medication.
- D. I’ll change positions slowly, especially when standing.
Correct answer: B
Rationale: The correct answer is B because methadone typically causes sedation and respiratory depression, not trouble sleeping. The statement about trouble sleeping indicates a need for further teaching. Choices A, C, and D are incorrect because understanding that methadone slows breathing, avoiding alcohol while taking the medication, and changing positions slowly to prevent dizziness are all appropriate client statements when prescribed methadone.
5. A nurse is assessing a client who had a stroke and is showing signs of dysphagia. Which finding indicates this condition?
- A. Abnormal mouth movements
- B. Inability to stand without assistance
- C. Paralysis of the right arm
- D. Loss of appetite
Correct answer: A
Rationale: Abnormal mouth movements are a key sign of dysphagia, a condition commonly seen in stroke clients. Dysphagia refers to difficulty swallowing, which can manifest as abnormal movements of the mouth during eating or drinking. In stroke patients, dysphagia increases the risk of aspiration, where food or liquids enter the airway instead of the esophagus, leading to potential complications such as pneumonia. Choices B, C, and D are not directly indicative of dysphagia. Inability to stand without assistance may indicate motor deficits, paralysis of the right arm suggests a neurological impairment, and loss of appetite can be a non-specific symptom in many conditions but does not specifically point to dysphagia.
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