ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A client with preeclampsia is receiving magnesium sulfate intravenously. What action should the nurse take if the client develops toxicity?
- A. Position the client supine
- B. Prepare an IV bolus of dextrose 5%
- C. Administer calcium gluconate IV
- D. Administer methylergonovine IM
Correct answer: C
Rationale: In cases of magnesium sulfate toxicity, calcium gluconate is the antidote as it helps reverse the effects. Positioning the client supine (Choice A) may not directly address magnesium sulfate toxicity. Administering dextrose 5% (Choice B) is not the correct intervention for magnesium sulfate toxicity. Methylergonovine IM (Choice D) is used to manage postpartum hemorrhage, not magnesium sulfate toxicity.
2. A nurse is caring for a client who has peptic ulcer disease (PUD) and is prescribed sucralfate. Which of the following instructions should the nurse include in the teaching?
- A. Take sucralfate with an antacid.
- B. Take sucralfate 1 hour before meals.
- C. Take sucralfate with food.
- D. Take sucralfate at bedtime only.
Correct answer: B
Rationale: The correct answer is B. Sucralfate should be taken on an empty stomach, 1 hour before meals. This timing allows sucralfate to form a protective barrier over the ulcer, enhancing healing. Choice A is incorrect because sucralfate should not be taken with an antacid. Choice C is incorrect because sucralfate should not be taken with food. Choice D is incorrect because sucralfate should not be taken at bedtime only; it is best absorbed on an empty stomach.
3. A client is being taught how to use crutches by a nurse. Which of the following instructions should the nurse include?
- A. Place weight on the underarms.
- B. Keep the elbows extended when walking.
- C. Support your weight on your hands.
- D. Hold the crutches 10 cm in front of you when standing.
Correct answer: C
Rationale: The correct answer is C: 'Support your weight on your hands.' When using crutches, it is important to support your weight on your hands rather than underarms to prevent injury to the axillary nerves and blood vessels. Placing weight on the underarms can lead to nerve damage and circulatory issues. Choices A, B, and D are incorrect. Keeping the elbows extended when walking is important for stability, holding the crutches slightly in front of you allows for proper balance, and supporting weight on the hands maintains the correct weight-bearing position.
4. A nurse is assessing a newborn following a vaginal delivery. Which of the following findings should the nurse report to the provider?
- A. Vernix caseosa
- B. Head circumference of 34 cm
- C. Jaundice at 24 hours of age
- D. Respiratory rate of 50/min
Correct answer: C
Rationale: Jaundice within the first 24 hours of life is considered pathological and may indicate hemolytic disease or another serious condition, requiring further investigation.
5. A nurse is teaching a client about the use of atorvastatin. Which of the following should be included?
- A. Monitor for muscle pain
- B. It can cause weight gain
- C. It is safe during pregnancy
- D. It is an anticoagulant
Correct answer: A
Rationale: The correct answer is A: 'Monitor for muscle pain.' Atorvastatin can cause muscle pain and liver function abnormalities, so clients should be monitored for these side effects. Choice B is incorrect because atorvastatin is not known to cause weight gain. Choice C is incorrect as atorvastatin is contraindicated during pregnancy due to potential harm to the fetus. Choice D is incorrect because atorvastatin is a statin medication used to lower cholesterol levels, not an anticoagulant.
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