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 caring for a client who has a new prescription for amphotericin B. The nurse should plan to monitor the client for which of the following adverse effects?
- A. Hyperkalemia
- B. Hypertension
- C. Constipation
- D. Nephrotoxicity
Correct answer: D
Rationale: Correct. Amphotericin B is known for its nephrotoxicity, which can lead to kidney damage. Monitoring kidney function is crucial to detect any signs of nephrotoxicity early. Choices A, B, and C are incorrect because hyperkalemia, hypertension, and constipation are not typically associated with amphotericin B use. Therefore, the nurse should focus on monitoring for nephrotoxicity.
3. A nurse is planning to administer epoetin alfa to a client who has chronic kidney failure. Which of the following data should the nurse plan to review prior to administration of this medication?
- A. Blood pressure
- B. Temperature
- C. Blood glucose levels
- D. Total protein levels
Correct answer: A
Rationale: The correct answer is A: Blood pressure. Epoetin alfa can increase blood pressure, especially in clients with chronic kidney failure. Monitoring blood pressure before administration is crucial to prevent hypertension. Reviewing temperature, blood glucose levels, or total protein levels is not directly related to the potential side effect of increased blood pressure associated with epoetin alfa.
4. A nurse is providing teaching to a newly licensed nurse about administering morphine via IV bolus to a client. Which of the following information should the nurse include in the teaching?
- A. Respiratory depression can occur within 7 minutes after the morphine is administered.
- B. The morphine will peak within a few minutes.
- C. Withhold the morphine if the client has a respiratory rate less than 16/min.
- D. Administer the morphine over 2 minutes.
Correct answer: A
Rationale: The correct answer is A because respiratory depression is a significant risk when administering morphine, and it can occur within 7 minutes after administration. This information is crucial for the nurse to recognize and respond promptly. Choice B is incorrect because the peak effect of morphine via IV bolus is typically reached within a few minutes, not specifically 10 minutes. Choice C is incorrect because withholding morphine based solely on a respiratory rate less than 16/min may not be appropriate without considering other factors such as pain level, oxygen saturation, and overall respiratory status. Choice D is incorrect because administering morphine over 2 minutes may not prevent respiratory depression if it occurs rapidly after administration. Nurses should be vigilant for signs of respiratory depression regardless of the administration duration.
5. A client at 28 weeks of gestation is experiencing preterm labor. Which of the following medications should the nurse plan to administer?
- A. Oxytocin
- B. Nifedipine
- C. Dinoprostone
- D. Misoprostol
Correct answer: B
Rationale: Nifedipine is the correct choice because it is a calcium channel blocker that helps relax the uterus and stop preterm labor. Oxytocin (Choice A) is used to induce labor, not to stop preterm labor. Dinoprostone (Choice C) and Misoprostol (Choice D) are prostaglandins used to induce labor and ripen the cervix, not to stop preterm labor.