ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A client is receiving morphine. Which of the following should the nurse monitor?
- A. Liver function
- B. Respiratory rate
- C. Blood glucose levels
- D. Bowel sounds
Correct answer: B
Rationale: Corrected Rationale: When a client is receiving morphine, monitoring the respiratory rate is crucial because morphine can cause respiratory depression. Therefore, it is essential for the nurse to assess the client's breathing to detect any signs of respiratory distress. Choices A, C, and D are incorrect because morphine primarily affects the respiratory system, not the liver function, blood glucose levels, or bowel sounds.
2. A healthcare professional is preparing to administer morphine for severe pain. What is the priority assessment the professional should make before administration?
- A. Blood pressure
- B. Respiratory rate
- C. Heart rate
- D. Temperature
Correct answer: B
Rationale: Before administering morphine, the priority assessment the healthcare professional should make is the client's respiratory rate. Morphine can cause respiratory depression, so assessing the respiratory rate is crucial to prevent any potential complications. Assessing blood pressure, heart rate, and temperature are important as well, but they are not the priority when administering morphine for severe pain.
3. A client who is being admitted for induction of labor is receiving teaching about newborn safety from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will check the identification badge of anyone who removes my baby from our room.
- B. I should include a photo of my baby along with any public birth announcements on social media.
- C. I will allow my baby to sleep on the bed in my room when I am in the shower.
- D. I should expect the nurses to carry my baby in their arms to the nursery.
Correct answer: A
Rationale: Choice A is the correct answer because the client should verify the identification badge of anyone removing their baby to ensure the infant's safety and prevent abduction. This statement demonstrates an understanding of the importance of strict identification protocols in the hospital setting. Choice B is incorrect because including a photo of the baby in public announcements does not relate to newborn safety teaching. Choice C is incorrect as it is unsafe to allow a baby to sleep on the bed unsupervised. Choice D is incorrect because nurses typically encourage parents to carry their baby to the nursery themselves for bonding and security reasons.
4. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate. The nurse should monitor the client for which of the following findings as an indication of magnesium toxicity?
- A. Decreased deep tendon reflexes
- B. Elevated blood pressure
- C. Increased urinary output
- D. Hyperreflexia
Correct answer: A
Rationale: The correct answer is A: Decreased deep tendon reflexes. Magnesium sulfate toxicity can lead to diminished deep tendon reflexes, respiratory depression, and decreased urine output. Diminished deep tendon reflexes are an early sign of magnesium toxicity and indicate the need to discontinue the infusion. Elevated blood pressure (choice B) is not typically associated with magnesium toxicity. Increased urinary output (choice C) is also not a common finding in magnesium toxicity. Hyperreflexia (choice D) is not consistent with the expected findings of magnesium toxicity, which typically causes decreased reflexes.
5. A healthcare professional is teaching a client about reducing the risk of urinary tract infections (UTIs). Which factor increases the risk of UTI?
- A. Wearing underwear with a cotton crotch
- B. Wiping from front to back
- C. Using perfumed toilet paper
- D. Urinating after intercourse
Correct answer: C
Rationale: Using perfumed toilet paper can irritate the urinary tract and increase the risk of UTI, so it should be avoided. Wearing underwear with a cotton crotch (Choice A) is a preventive measure as cotton allows for better air circulation and reduces moisture, lowering the risk of UTIs. Wiping from front to back (Choice B) helps prevent the introduction of bacteria from the anal region to the urinary tract. Urinating after intercourse (Choice D) can help flush out bacteria introduced during sexual activity, thereby reducing the risk of UTIs.
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