ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A client has a stool culture positive for C. difficile. What action should the nurse take?
- A. Place the client in a negative pressure room
- B. Use alcohol-based hand rub after providing care
- C. Wear a face shield before entering the room
- D. Place the client in a private room
Correct answer: D
Rationale: When caring for a client with a C. difficile infection, it is essential to isolate them in a private room to prevent the spread of spores through contact with surfaces. Placing the client in a negative pressure room (Choice A) is not necessary for C. difficile. Using alcohol-based hand rub (Choice B) and wearing a face shield (Choice C) are important infection control measures but are not specific to the isolation requirements for C. difficile.
2. A healthcare provider is teaching a client about the use of prednisone. Which of the following should be included?
- A. It should not be stopped abruptly
- B. It may cause weight gain
- C. It has no side effects
- D. Take it regularly regardless of symptoms
Correct answer: B
Rationale: The correct answer is B. Prednisone can cause weight gain and other side effects, so clients should be informed about these potential risks. Choice A is incorrect because prednisone should not be stopped abruptly to prevent withdrawal symptoms. Choice C is incorrect because prednisone can have various side effects. Choice D is incorrect because prednisone is usually prescribed with specific dosing instructions and should not be taken irregularly or only when symptoms occur.
3. A client who has undergone a cesarean birth is receiving discharge instructions from a nurse. Which of the following should the nurse include in the instructions?
- A. Limit stair climbing for the first few weeks
- B. Avoid lifting anything heavier than the newborn
- C. Use a pillow to support the abdomen when coughing or sneezing
- D. All of the above
Correct answer: D
Rationale: After a cesarean birth, it is important for the client to follow specific instructions for optimal recovery. Limiting stair climbing reduces strain on the incision site, aiding in healing (Choice A). Avoiding lifting anything heavier than the newborn prevents stress on the incision, promoting recovery (Choice B). Using a pillow to support the abdomen during coughing or sneezing helps reduce discomfort and protect the incision, preventing sudden movements or strain (Choice C). Therefore, all the options provided are crucial post-cesarean birth instructions to ensure proper healing and recovery. Choices A, B, and C are all essential components of post-cesarean care, making Option D the correct answer.
4. A nurse is admitting a client who is at 33 weeks of gestation and has preeclampsia with severe features. Which of the following actions should the nurse take?
- A. Restrict protein intake to less than 40 g/day
- B. Initiate seizure precautions for the client
- C. Initiate an infusion of 0.9% sodium chloride at 150 mL/hr
- D. Encourage the client to ambulate twice per day
Correct answer: B
Rationale: The correct action for the nurse to take is to initiate seizure precautions for the client. Severe preeclampsia increases the risk of seizures (eclampsia), making it crucial to prioritize the safety of the client. Restricting protein intake (Choice A) is not the priority in this situation as seizure prevention takes precedence. While maintaining hydration is essential, starting an infusion of 0.9% sodium chloride (Choice C) is not the initial action needed for seizure prevention. Encouraging the client to ambulate (Choice D) may not be safe or appropriate considering the severity of preeclampsia and the risk of seizures.
5. A nurse is providing teaching for a child who is prescribed ferrous sulfate. Which of the following instructions should the nurse include?
- A. Take the medication with milk
- B. Take with a glass of orange juice
- C. Take at bedtime
- D. Take with meals
Correct answer: B
Rationale: The correct answer is B: 'Take with a glass of orange juice.' Ferrous sulfate should be taken with orange juice (vitamin C) to enhance the absorption of iron. Taking it with milk (choice A) is not recommended as calcium can interfere with iron absorption. Taking it at bedtime (choice C) or with meals (choice D) may lead to decreased absorption due to interactions with other food or medications.
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