ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client receiving oxytocin IV for labor augmentation. The client’s contractions are occurring every 45 seconds and lasting 90 seconds. What action should the nurse take?
- A. Discontinue the oxytocin infusion
- B. Increase the oxytocin infusion
- C. Decrease the oxytocin infusion
- D. Maintain the oxytocin infusion
Correct answer: A
Rationale: In this scenario, the client is experiencing uterine hyperstimulation with contractions every 45 seconds lasting 90 seconds. This frequency and duration of contractions can lead to fetal distress. The appropriate nursing action is to discontinue the oxytocin infusion immediately to prevent complications. Increasing or maintaining the oxytocin infusion would exacerbate the situation, while decreasing it may not be sufficient to address the issue effectively.
2. A nurse is providing teaching to a client about the Papanicolaou (Pap) test. Which of the following information should the nurse include in the teaching?
- A. A Pap test is recommended every 3 years for women aged 21-29 and every 3-5 years for women aged 30-65.
- B. Pap tests are recommended following removal of the ovaries.
- C. Avoid having sexual intercourse for 24 hours prior to the Pap test.
- D. Viral infections cannot be detected by a Pap test.
Correct answer: C
Rationale: Clients should avoid sexual intercourse for 24 hours prior to the Pap test to ensure accurate results, as it can affect the sample. This is important for obtaining reliable results. Choice A is incorrect because a yearly Pap test is not the standard recommendation for all age groups; instead, it is typically every 3 years for women aged 21-29 and every 3-5 years for women aged 30-65. Choice B is incorrect because Pap tests are not necessarily discontinued following removal of the ovaries; they may still be needed based on the individual's health history and provider recommendations. Choice D is incorrect because while Pap tests are primarily used to detect abnormal cervical cells and cervical cancer, they do not detect viral infections.
3. A nurse is caring for a client who has a new prescription for ergotamine. The nurse should recognize that ergotamine is administered to treat which of the following conditions?
- A. Raynaud's phenomenon
- B. Migraine headaches
- C. Ulcerative colitis
- D. Anemia
Correct answer: B
Rationale: Ergotamine is used to treat migraine headaches by constricting blood vessels in the brain. Therefore, the correct answer is B. Choice A, Raynaud's phenomenon, is incorrect as ergotamine is not indicated for this condition. Choice C, Ulcerative colitis, is incorrect as ergotamine is not used to treat this gastrointestinal disorder. Choice D, Anemia, is incorrect as ergotamine is not prescribed for anemia.
4. A healthcare provider is reviewing the medical records of a group of older adults (OA). The provider should identify that which of the following is a risk factor that places OA at an increased risk for developing infections?
- A. Improved circulation
- B. Increased immune function
- C. Lowered immune system function
- D. Dehydration
Correct answer: C
Rationale: The correct answer is C: 'Lowered immune system function.' As individuals age, their immune system tends to weaken, making them more susceptible to infections. Choices A, B, and D are incorrect because improved circulation and increased immune function would typically reduce the risk of infections, while dehydration can impact overall health but is not directly related to immune system function in the context of infection risk.
5. A client with a history of chronic obstructive pulmonary disease (COPD) presents with increasing shortness of breath. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Barrel-shaped chest.
- B. Use of accessory muscles to breathe.
- C. Oxygen saturation of 88%.
- D. Respiratory rate of 22 breaths per minute.
Correct answer: C
Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical finding in a client with COPD. Hypoxemia can lead to serious complications and may require immediate intervention, such as adjusting oxygen therapy to improve oxygenation levels and prevent further respiratory distress. Monitoring and maintaining adequate oxygen saturation is crucial in managing COPD exacerbations and preventing respiratory failure.
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