ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is caring for a client who has a nasogastric (NG) tube and is receiving enteral feedings. The client reports feeling nauseated. Which of the following actions should the nurse take first?
- A. Administer an antiemetic.
- B. Check the client’s bowel sounds.
- C. Slow the rate of the feeding.
- D. Place the client in a supine position.
Correct answer: B
Rationale: The correct action for the nurse to take first when a client with a nasogastric tube reports feeling nauseated is to check the client's bowel sounds. This assessment helps the nurse evaluate for possible complications, such as a blockage or decreased gastric motility, that could be causing the nausea. Administering an antiemetic (Choice A) should not be the first action without assessing the underlying cause of the nausea. Slowing the rate of the feeding (Choice C) may be appropriate but is not the priority until further assessment is done. Placing the client in a supine position (Choice D) is not typically indicated for managing nausea in this situation.
2. A nurse is assessing a client who gave birth 1 week ago. The client states, 'I don't know what's wrong. I love my baby, but I feel so let down and I seem to cry for no reason.' The nurse should identify that the client is experiencing which of the following emotional responses to birth?
- A. Postpartum depression
- B. Taking-in phase
- C. Postpartum blues
- D. Taking-hold phase
Correct answer: C
Rationale: The client is experiencing postpartum blues, not postpartum depression. Postpartum blues are common and characterized by mood swings, tearfulness, and emotional letdown shortly after delivery. The 'Taking-in phase' involves the mother focusing on her own needs, while the 'Taking-hold phase' is characterized by a desire to learn and feel competent in caring for the baby. Postpartum depression is a more severe and long-lasting condition that requires professional intervention.
3. A nurse is caring for a client who is 8 hours postpartum following a vaginal birth. The client reports passing large clots and heavy bleeding. Which of the following actions should the nurse take?
- A. Massage the fundus
- B. Administer methylergonovine
- C. Increase the IV fluid rate
- D. Notify the healthcare provider
Correct answer: A
Rationale: Heavy bleeding and the passage of large clots after childbirth can indicate uterine atony. The nurse should first attempt to massage the fundus to stimulate uterine contractions and control the bleeding. Massaging the fundus helps the uterus to contract and may help prevent further bleeding. Administering methylergonovine (Choice B) is not the initial intervention for uterine atony. Increasing the IV fluid rate (Choice C) may not address the underlying cause of the bleeding. Notifying the healthcare provider (Choice D) can be done after attempting initial interventions like fundal massage.
4. While assessing the IV infusion site of a client who reports pain at the site, a nurse notes redness and warmth along the vein. What should the nurse do?
- A. Continue the infusion
- B. Increase the infusion rate
- C. Discontinue the infusion
- D. Apply a cold compress
Correct answer: C
Rationale: The symptoms described indicate phlebitis, which is inflammation of the vein. In this case, the nurse should discontinue the infusion to prevent further complications. Continuing the infusion or increasing the rate can exacerbate the condition. Applying a cold compress is not recommended for phlebitis; instead, a warm compress can help alleviate discomfort.
5. A client has been taking propranolol. Which of the following findings indicates a need to withhold the medication?
- A. Sodium 130 mEq/L
- B. Blood pressure 156/90 mm Hg
- C. Potassium 5.2 mEq/L
- D. Pulse 54/min
Correct answer: D
Rationale: A pulse of 54/min indicates bradycardia, which is a side effect of propranolol, a beta-blocker. The medication should be withheld if the client's pulse drops below 60/min. The other findings (sodium levels, blood pressure, and potassium levels) are not directly indicative of the need to withhold propranolol.
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