ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is caring for a client who has liver cirrhosis and ascites. Which of the following actions should the nurse take to monitor the effectiveness of the treatment?
- A. Measure the client’s abdominal girth daily
- B. Monitor the client’s hemoglobin level
- C. Administer lactulose as prescribed
- D. Weigh the client weekly
Correct answer: A
Rationale: Measuring the client’s abdominal girth daily is the most effective way to monitor the reduction of ascites and fluid retention in clients with liver cirrhosis. This measurement helps assess the effectiveness of treatment in managing ascites by monitoring changes in abdominal size. Monitoring the client’s hemoglobin level (Choice B) is not directly related to assessing the effectiveness of ascites treatment. Administering lactulose as prescribed (Choice C) is important in managing hepatic encephalopathy, not ascites. Weighing the client weekly (Choice D) may not provide real-time feedback on the reduction of ascites compared to daily abdominal girth measurements.
2. A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?
- A. Increase in frequency of swallowing.
- B. Moderate sanguineous drainage on the drip pad.
- C. Bruising to the face.
- D. Absent gag reflex.
Correct answer: A
Rationale: The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.
3. A nurse is preparing to administer a dose of iron supplement. Which of the following should the nurse do?
- A. Give it with milk
- B. Administer it on an empty stomach
- C. Check blood pressure
- D. Monitor for allergic reactions
Correct answer: B
Rationale: The correct answer is B: Administer it on an empty stomach. Iron supplements are best absorbed on an empty stomach to enhance their absorption. It is important to avoid giving them with milk or dairy products as these can inhibit iron absorption. Checking blood pressure and monitoring for allergic reactions are not directly related to the administration of iron supplements and are not the primary considerations in this case.
4. A nurse is caring for a client who has a prescription for clopidogrel. The nurse should monitor the client for which of the following adverse effects?
- A. Insomnia
- B. Hypotension
- C. Bleeding
- D. Constipation
Correct answer: C
Rationale: The correct answer is C: Bleeding. Clopidogrel is an antiplatelet medication that works by preventing platelets from sticking together and forming clots. Therefore, one of the main adverse effects of clopidogrel is an increased risk of bleeding. Insomnia (Choice A), hypotension (Choice B), and constipation (Choice D) are not commonly associated with clopidogrel use. Monitoring for signs of bleeding, such as easy bruising, petechiae, or prolonged bleeding from minor cuts, is crucial when a client is taking clopidogrel.
5. A nurse is instructing a group of nursing students about the responsibilities involved with organ donation and procurement. When the nurse explains that all clients waiting for a kidney transplant have to meet the same qualifications, the students should understand that this aspect of care delivery is an example of which ethical principle?
- A. Fidelity
- B. Autonomy
- C. Justice
- D. Non-maleficence
Correct answer: C
Rationale: The correct answer is C: Justice. Justice in healthcare ethics refers to fairness and equality in the distribution of resources and treatments. In this scenario, ensuring that all clients waiting for a kidney transplant meet the same qualifications demonstrates the ethical principle of justice by providing equal opportunities for all candidates. Choice A, fidelity, pertains to keeping promises and being faithful to agreements, which is not the primary ethical principle at play in this situation. Autonomy, choice B, relates to respecting a patient's right to make their own decisions, which is not directly applicable in the context of organ transplant qualifications. Non-maleficence, choice D, refers to the principle of doing no harm, which is important but not the primary ethical principle highlighted in this scenario.
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