ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is caring for a client who has been receiving oxytocin IV for labor augmentation. The client's contractions are occurring every 2 minutes and lasting 90 seconds. What action should the nurse take?
- A. Decrease the oxytocin infusion
- B. Discontinue the oxytocin infusion
- C. Increase the IV fluid rate
- D. Apply an internal fetal monitor
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. The client is experiencing uterine hyperstimulation, as evidenced by contractions occurring every 2 minutes and lasting 90 seconds. Discontinuing the oxytocin is crucial to prevent fetal distress and uterine rupture. Increasing the IV fluid rate would not address the uterine hyperstimulation caused by oxytocin. Applying an internal fetal monitor is not the priority at this moment; first, the oxytocin infusion needs to be stopped to manage the uterine hyperstimulation effectively.
2. What is the primary action of amlodipine when prescribed to a patient with hypertension?
- A. Increase heart rate
- B. Reduce blood pressure
- C. Lower cholesterol levels
- D. Decrease blood sugar levels
Correct answer: B
Rationale: Amlodipine is a calcium channel blocker that works by relaxing the blood vessels, leading to a reduction in blood pressure. This medication does not increase heart rate, lower cholesterol levels, or decrease blood sugar levels.
3. A patient with panic disorder is prescribed selective serotonin reuptake inhibitors (SSRIs). What should the nurse include in the patient’s education?
- A. SSRIs are fast-acting medications that can relieve anxiety immediately.
- B. It may take several weeks for the full therapeutic effects of SSRIs to be felt.
- C. SSRIs have a high potential for abuse and dependence.
- D. The patient should discontinue the medication once they feel better.
Correct answer: B
Rationale: Patients prescribed with SSRIs need to be educated that it may take several weeks for the full therapeutic effects of the medication to be experienced. This delay is important for patient understanding and compliance with the treatment plan. Choice A is incorrect because SSRIs do not provide immediate relief and may take weeks to show significant improvement. Choice C is inaccurate as SSRIs are not known for having a high potential for abuse and dependence. Choice D is incorrect as patients should never discontinue medication abruptly without consulting their healthcare provider.
4. During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
- A. An irregularly shaped, nontender lump palpable in the right breast
- B. Tenderness present during menstruation
- C. Bilateral, symmetrical lumps that move with palpation
- D. The client reports breast tenderness before menstruation
Correct answer: A
Rationale: An irregularly shaped, nontender lump is a concerning finding as it may indicate breast cancer. The nurse should report this finding to the provider for further investigation. Choices B, C, and D are less concerning findings. Tenderness during menstruation is a common finding due to hormonal changes. Bilateral, symmetrical lumps that move with palpation are often benign findings like fibrocystic changes. Breast tenderness before menstruation is also a common occurrence related to hormonal fluctuations.
5. A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?
- A. Take vital signs
- B. Assess lochia
- C. Massage the fundus
- D. Give oxytocin IV bolus
Correct answer: C
Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.
Similar Questions
Access More Features
ATI Basic
- 50,000 Questions with answers
- All ATI courses Coverage
- 30 days access @ $69.99
ATI Basic
- 50,000 Questions with answers
- All ATI courses Coverage
- 90 days access @ $149.99