ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is caring for a client who has a prescription for chlorothiazide to treat hypertension. The nurse should plan to monitor the client for which of the following adverse effects?
- A. Thrombophlebitis
- B. Hyperactive reflexes
- C. Muscle weakness
- D. Hypoglycemia
Correct answer: C
Rationale: The correct answer is C: Muscle weakness. Chlorothiazide, a thiazide diuretic, can lead to hypokalemia, which can cause muscle weakness. Thrombophlebitis (choice A) is not typically associated with chlorothiazide use. Hyperactive reflexes (choice B) and hypoglycemia (choice D) are also not commonly linked to this medication. Therefore, monitoring for muscle weakness is crucial when a client is prescribed chlorothiazide.
2. A nurse is preparing to administer prochlorperazine 2.5 mg IV. Available is prochlorperazine injection 5 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth)
- A. 0.5 mL
- B. 0.005 mL
- C. 0.05 mL
- D. 5 mL
Correct answer: A
Rationale: To calculate the mL needed, set up a proportion: 5 mg / 1 mL = 2.5 mg / X mL. Cross multiply to find X: 5 * X = 2.5 * 1, X = 2.5 / 5 = 0.5 mL. Therefore, the nurse should administer 0.5 mL. Choice B, 0.005 mL, is incorrect as it doesn't match the calculated result. Choice C, 0.05 mL, is incorrect as it is ten times the correct value. Choice D, 5 mL, is incorrect as it represents the total volume of the entire vial, not the amount needed for the specific dose.
3. A nurse is providing teaching to a client who has a new prescription for hydrochlorothiazide 50 mg PO daily to treat hypertension. Which of the following instructions should the nurse include in the teaching?
- A. Take hydrochlorothiazide as needed for edema.
- B. Check your weight once weekly.
- C. Take the hydrochlorothiazide on an empty stomach.
- D. Take the hydrochlorothiazide in the morning.
Correct answer: D
Rationale: The correct answer is to take hydrochlorothiazide in the morning. This medication is usually advised to be taken in the morning to prevent nocturia, which is excessive urination at night. Option A is incorrect because hydrochlorothiazide should be taken daily as prescribed, not as needed for edema. Option B is incorrect as monitoring weight weekly may not be specifically related to hydrochlorothiazide therapy. Option C is incorrect as hydrochlorothiazide does not need to be taken on an empty stomach.
4. A nurse is providing teaching to a client who has cirrhosis and a new prescription for lactulose. The nurse should instruct the client that lactulose has which of the following therapeutic effects?
- A. Increases blood pressure
- B. Prevents esophageal bleeding
- C. Decreases heart rate
- D. Reduces ammonia levels
Correct answer: D
Rationale: The correct answer is D: Reduces ammonia levels. Lactulose is used to reduce blood ammonia levels in clients with hepatic encephalopathy. Options A, B, and C are incorrect because lactulose does not have the therapeutic effect of increasing blood pressure, preventing esophageal bleeding, or decreasing heart rate.
5. A nurse is reviewing the laboratory values for a client who is receiving a continuous IV heparin infusion and has an aPTT of 90 seconds. Which of the following actions should the nurse prepare to take?
- A. Administer vitamin K
- B. Reduce the infusion rate
- C. Give the client a low-dose aspirin
- D. Request an INR
Correct answer: B
Rationale: An aPTT of 90 seconds is elevated, indicating a risk of bleeding due to excessive anticoagulation. The appropriate action is to reduce the infusion rate of heparin to prevent further complications. Administering vitamin K is not indicated for an elevated aPTT due to heparin therapy. Giving the client a low-dose aspirin can further increase the risk of bleeding when combined with heparin. Requesting an INR is not necessary for monitoring heparin therapy; aPTT is the more specific test for assessing heparin's therapeutic effect. Therefore, the correct action for the nurse to prepare to take is to reduce the infusion rate of heparin.
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