ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client who has mild anxiety. Which of the following findings should the nurse expect?
- A. Feelings of dread
- B. Rapid speech
- C. Purposeless activity
- D. Heightened perceptual field
Correct answer: D
Rationale: In mild anxiety, the client is expected to have a heightened perceptual field. This means that their perception is increased, enhancing their awareness and ability to concentrate. Feelings of dread (Choice A) are more common in moderate to severe anxiety. Rapid speech (Choice B) and purposeless activity (Choice C) are more indicative of moderate to severe anxiety where the individual may exhibit signs of agitation and restlessness.
2. A client newly diagnosed with nephrotic syndrome is being taught by a nurse. Which statement indicates that the client understands the teaching?
- A. “I can expect swelling in my hands and on my face.â€
- B. “The amount of protein in my blood is high.â€
- C. “I might have some pain and gas in my stomach from this condition.â€
- D. “I will use a soft bristle toothbrush, so my gums don’t bleed.â€
Correct answer: A
Rationale: The correct answer is A: “I can expect swelling in my hands and on my face.†Nephrotic syndrome leads to increased permeability of the glomeruli, resulting in edema, especially in the face and dependent areas. Choice B is incorrect because nephrotic syndrome leads to protein loss in the urine, not an increase in blood protein levels. Choice C is incorrect as stomach pain and gas are not typical symptoms of nephrotic syndrome. Choice D is unrelated to the teaching about nephrotic syndrome and gum bleeding.
3. A client has a new prescription for levothyroxine. What should the nurse teach the client?
- A. It should be taken at night
- B. Monitor for symptoms of hypothyroidism
- C. Take it with calcium supplements
- D. Take it on an empty stomach
Correct answer: D
Rationale: The correct answer is to take levothyroxine on an empty stomach. This is because levothyroxine should be taken in the morning on an empty stomach to ensure proper absorption. Option A is incorrect because levothyroxine is usually advised to be taken in the morning. Option B is not the priority teaching point as monitoring for hypothyroidism symptoms is ongoing care. Option C is incorrect as levothyroxine should not be taken with calcium supplements as they can interfere with its absorption.
4. A nurse is caring for a client who has breast cancer and has been receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider?
- A. WBC 3,000/mm3
- B. Hemoglobin 14 g/dL
- C. Platelets 250,000/mm3
- D. aPTT 30 seconds
Correct answer: A
Rationale: A WBC count of 3,000/mm3 indicates neutropenia, a dangerous complication of chemotherapy that increases the risk of infection and requires immediate attention. Neutropenia is a common side effect of chemotherapy and can lead to life-threatening infections. Reporting a low WBC count is crucial to ensure timely intervention. Choices B, C, and D are within normal ranges and do not pose immediate risks to the client undergoing chemotherapy.
5. A client receiving IV moderate (conscious) sedation with midazolam has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse?
- A. Place the client in a prone position
- B. Implement positive pressure ventilation
- C. Perform nasopharyngeal suctioning
- D. Administer flumazenil
Correct answer: D
Rationale: In this scenario, the client is showing signs of respiratory depression and central nervous system depression due to midazolam sedation. Administering flumazenil is the correct action as it is the antidote for midazolam, a benzodiazepine, and can reverse the sedative effects to restore respiratory function. Placing the client in a prone position (choice A) may worsen respiratory compromise. Implementing positive pressure ventilation (choice B) is not the first-line intervention for sedation-related respiratory depression. Performing nasopharyngeal suctioning (choice C) is not indicated as there are no signs of airway obstruction requiring suctioning.
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