ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A client had a pituitary tumor removed. Which of the following findings requires further assessment?
- A. Glasgow scale score of 15
- B. Blood drainage on dressing measuring 3 cm
- C. Report of dry mouth
- D. Urinary output greater than fluid intake
Correct answer: D
Rationale: The correct answer is D. Increased urinary output greater than fluid intake can indicate diabetes insipidus, a common complication after pituitary surgery. Diabetes insipidus is characterized by the excretion of a large volume of dilute urine, leading to dehydration and electrolyte imbalances. This finding requires immediate assessment and intervention. Choice A, a Glasgow scale score of 15, indicates normal neurological functioning. Choice B, blood drainage on dressing measuring 3 cm, may require monitoring but is not a priority over the potential complication of diabetes insipidus. Choice C, a report of dry mouth, is a common complaint postoperatively and can be managed with oral care measures.
2. A nurse is providing discharge instructions to parents of a circumcised newborn. To prevent diaper adherence to the penis, what will be recommended to apply during diaper changes?
- A. Baby oil
- B. Antibiotic ointment
- C. Petroleum jelly
- D. Alcohol wipes
Correct answer: C
Rationale: Petroleum jelly is recommended to prevent the diaper from sticking to the circumcised area, reducing irritation and promoting healing. It should be applied during every diaper change until the site heals. Baby oil (Choice A) is not recommended as it may not provide a sufficient barrier to prevent adherence. Antibiotic ointment (Choice B) is not typically used for this purpose and can sometimes cause irritation. Alcohol wipes (Choice D) are too harsh for the sensitive skin of a newborn and can cause irritation.
3. A nurse is caring for a patient who has been in a motor vehicle crash and has a minor traumatic brain injury (TBI). What finding should the nurse recognize as a complication and report to the provider?
- A. Hypertension
- B. Vomiting
- C. Drainage from the ear
- D. Unequal pupils
Correct answer: D
Rationale: Unequal pupils are a sign of increased intracranial pressure or worsening brain injury, indicating a serious complication that requires immediate medical attention. Hypertension, vomiting, and drainage from the ear are not typically associated with minor traumatic brain injury complications; therefore, they are not the priority findings to report to the provider.
4. A nurse is caring for a client receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?
- A. Stop the infusion.
- B. Slow the infusion.
- C. Apply a warm compress to the site.
- D. Apply a cold compress to the site.
Correct answer: A
Rationale: Corrected Rationale: If infiltration is suspected, the nurse should immediately stop the dopamine infusion to prevent further damage to the surrounding tissue. Choice A is the correct answer because continuing the infusion can lead to tissue damage and compromise the client's care. Slowing the infusion (Choice B) is not sufficient to prevent harm and may still cause damage. Applying a warm compress (Choice C) or a cold compress (Choice D) is not the recommended action for infiltration; stopping the infusion is crucial to prevent complications.
5. A client is prescribed omeprazole. Which of the following should the nurse monitor?
- A. Liver function
- B. Magnesium levels
- C. Blood glucose
- D. Hemoglobin levels
Correct answer: B
Rationale: Corrected Rationale: Omeprazole can cause hypomagnesemia, a condition characterized by low magnesium levels in the blood. Monitoring magnesium levels is crucial to detect and address this potential adverse effect. Liver function (Choice A) is not typically affected by omeprazole. Blood glucose (Choice C) and hemoglobin levels (Choice D) are not directly impacted by omeprazole administration. Therefore, magnesium levels (Choice B) are the most appropriate parameter to monitor in a client prescribed omeprazole.
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