ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is caring for a client who has a deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate frequently.
- B. Apply warm, moist compresses to the affected leg.
- C. Massage the affected leg.
- D. Place the client in a supine position.
Correct answer: B
Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply warm, moist compresses to the affected leg. This helps alleviate pain and improve circulation in the affected area, aiding in the treatment of DVT. Encouraging the client to ambulate frequently (Choice A) is contraindicated as it can dislodge the clot and lead to complications. Massaging the affected leg (Choice C) is also contraindicated as it can dislodge the clot and potentially cause an embolism. Placing the client in a supine position (Choice D) is not specifically indicated for DVT treatment; elevation of the affected leg is preferred over placing the client completely supine.
2. A client has been prescribed raloxiphene. As the nurse, you know that raloxiphene is used to treat:
- A. Migraines
- B. Hypertension
- C. Osteoporosis
- D. Heart disease
Correct answer: C
Rationale: Raloxiphene (Evista) is a selective estrogen receptor modulator (SERM) used primarily to prevent and treat osteoporosis in postmenopausal women. It helps to maintain bone density and reduce the risk of fractures by mimicking the effects of estrogen on bone tissue. It is not indicated for the treatment of migraines, hypertension, or heart disease. Therefore, the correct answer is osteoporosis (Choice C). Choices A, B, and D are incorrect as raloxiphene is not used to treat migraines, hypertension, or heart disease.
3. While in the cafeteria, a nurse overhears two APs discussing a hospitalized patient. What action should the nurse take?
- A. Report the incident to the supervisor.
- B. Join the conversation to intervene.
- C. Quietly tell the APs that this is not appropriate.
- D. Ignore the conversation.
Correct answer: C
Rationale: The correct action for the nurse to take in this situation is to choose option C: 'Quietly tell the APs that this is not appropriate.' The nurse should immediately and discreetly address the situation, reminding the APs that discussing patient information in public areas violates confidentiality. Reporting the incident to the supervisor (option A) may be necessary if the behavior continues. Joining the conversation to intervene (option B) may escalate the situation and compromise patient confidentiality. Ignoring the conversation (option D) does not address the violation or prevent it from recurring.
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 providing teaching to a client who has mild persistent asthma and has been prescribed montelukast. Which of the following statements should the nurse include in the teaching?
- A. This medication can be used to help manage asthma symptoms during an acute asthma attack
- B. This medication should be taken before exercise and physical activity
- C. This medication should be taken regularly as prescribed without discontinuing abruptly
- D. This medication helps decrease swelling and mucus production
Correct answer: D
Rationale: Montelukast works as a leukotriene receptor antagonist, reducing inflammation and mucus production, which helps prevent asthma attacks but is not used for acute treatment. It is important for the client to understand that montelukast should be taken regularly to manage asthma symptoms and should not be abruptly discontinued. Taking the medication before exercise is not a typical instruction for montelukast.
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