ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A nurse is caring for a client who has been taking isoniazid and rifampin for 3 weeks for the treatment of active pulmonary tuberculosis (TB). The client reports his urine is an orange color. Which of the following statements should the nurse make?
- A. Stop taking the isoniazid for 3 days and the discoloration should go away.
- B. Rifampin can turn body fluids orange.
- C. I'll make an appointment for you to see the provider this afternoon.
- D. Isoniazid can cause bladder irritation.
Correct answer: B
Rationale: The correct answer is B: 'Rifampin can turn body fluids orange.' Rifampin is known to cause orange discoloration of body fluids, including urine. This side effect is harmless and does not indicate a need to stop the medication. Choice A is incorrect because stopping isoniazid will not resolve the orange urine discoloration caused by rifampin. Choice C is unnecessary at this point since the orange urine is a known side effect of rifampin and does not require an urgent provider visit. Choice D is incorrect because bladder irritation is not typically associated with isoniazid.
2. A client with chronic obstructive pulmonary disease (COPD) is being taught by a nurse about measures to improve breathing. Which of the following instructions should the nurse include?
- A. Use pursed-lip breathing during physical activity
- B. Breathe deeply and quickly during exercise
- C. Avoid using the incentive spirometer
- D. Avoid physical activity to conserve energy
Correct answer: A
Rationale: The correct instruction the nurse should include is to 'Use pursed-lip breathing during physical activity.' Pursed-lip breathing is a technique that helps improve breathing efficiency in individuals with COPD by preventing airway collapse and allowing for better air exchange. Choice B is incorrect because breathing deeply and quickly can lead to hyperventilation and worsen symptoms in COPD patients. Choice C is incorrect because the incentive spirometer is a device used to encourage deep breathing and improve lung function, so it should not be avoided. Choice D is incorrect because physical activity is important for maintaining overall health and should be encouraged in a controlled and appropriate manner for individuals with COPD.
3. A client with a tracheostomy is exhibiting signs of respiratory distress. What should the nurse do first?
- A. Notify the healthcare provider
- B. Suction the tracheostomy
- C. Administer a bronchodilator
- D. Increase the oxygen flow rate
Correct answer: B
Rationale: When a client with a tracheostomy is experiencing respiratory distress, the priority action is to suction the tracheostomy to clear the airway and improve breathing. This helps remove secretions or blockages that may be causing the distress. Notifying the healthcare provider (Choice A) can be done after ensuring immediate airway clearance. Administering a bronchodilator (Choice C) would not address the primary issue of airway clearance in a tracheostomy patient. Increasing the oxygen flow rate (Choice D) may be necessary but should come after ensuring the airway is clear.
4. A nurse is caring for a client who has deep vein thrombosis (DVT) of the left lower extremity. Which of the following actions should the nurse take?
- A. Position the client with the affected extremity higher than the heart
- B. Administer acetaminophen for pain
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct answer: D
Rationale: The correct answer is to withhold heparin IV infusion. The nurse should withhold heparin if there are signs of complications, such as bleeding, or if there are contraindications to continuing anticoagulation therapy. Positioning the client with the affected extremity higher than the heart helps reduce swelling and improve blood flow. Administering acetaminophen for pain management can be appropriate, but it is not the priority in this situation. Massaging the affected extremity can dislodge the clot and lead to serious complications, so it should be avoided.
5. A patient diagnosed with panic disorder asks the nurse about the purpose of deep breathing exercises. Which explanation by the nurse is most accurate?
- A. Deep breathing helps distract you from your anxiety.
- B. Deep breathing can prevent future panic attacks.
- C. Deep breathing helps reduce physical symptoms of anxiety.
- D. Deep breathing increases your overall lung capacity.
Correct answer: C
Rationale: Deep breathing helps reduce the physical symptoms of anxiety, such as rapid heartbeat and shortness of breath.