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 is experiencing alcohol withdrawal. Which of the following interventions should the nurse implement?
- A. Encourage frequent ambulation
- B. Administer lorazepam
- C. Provide a low-calorie diet
- D. Administer insulin as prescribed
Correct answer: B
Rationale: The correct intervention for a client experiencing alcohol withdrawal is to administer lorazepam. Lorazepam, a benzodiazepine, is commonly used to manage the symptoms of alcohol withdrawal by preventing seizures and reducing agitation and anxiety. Encouraging frequent ambulation (choice A) may not be safe during alcohol withdrawal due to potential instability and confusion. Providing a low-calorie diet (choice C) is not a priority during alcohol withdrawal, as the focus is on managing withdrawal symptoms. Administering insulin as prescribed (choice D) is unrelated to managing alcohol withdrawal symptoms.
3. A nurse is caring for a client who has a new diagnosis of tuberculosis (TB). The client has a productive cough and is started on airborne precautions. Which of the following interventions should the nurse implement?
- A. Wear an N95 respirator mask when caring for the client.
- B. Place the client in a semi-private room.
- C. Have the client wear a surgical mask during meals.
- D. Use a negative pressure air filtration system.
Correct answer: A
Rationale: The correct answer is to wear an N95 respirator mask when caring for the client with TB. This is crucial to prevent the nurse from inhaling the airborne particles that spread the infection. Choice B is incorrect because placing the client in a semi-private room does not address the protection of the nurse. Choice C is incorrect as having the client wear a surgical mask during meals is not sufficient to protect the nurse during all interactions. Choice D is incorrect as using a negative pressure air filtration system is more applicable to airborne infection isolation rooms in healthcare settings and not a standard intervention for nurses caring for a single client with TB.
4. A nurse is preparing to administer IV furosemide. Which of the following should the nurse monitor for during the infusion?
- A. Increased urinary output
- B. Ototoxicity
- C. Hypokalemia
- D. Hypoglycemia
Correct answer: C
Rationale: The correct answer is C: Hypokalemia. Furosemide is a loop diuretic that works by increasing the excretion of water and electrolytes, particularly potassium. Therefore, the nurse should monitor for hypokalemia, as low potassium levels can lead to various complications such as cardiac dysrhythmias. Choice A, increased urinary output, is an expected effect of furosemide due to its diuretic action but is not a side effect needing monitoring. Ototoxicity (Choice B) is a potential adverse effect of other medications like aminoglycoside antibiotics, not furosemide. Hypoglycemia (Choice D) is not a common side effect associated with furosemide administration.
5. A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority to report to the provider?
- A. Constipation
- B. Blurred vision
- C. Fever
- D. Dry mouth
Correct answer: C
Rationale: The correct answer is C: Fever. Clozapine can cause agranulocytosis, a serious condition that leads to infections. Fever may indicate an underlying infection, a potentially life-threatening complication, and must be reported immediately to the provider for further evaluation and management. Choice A (Constipation) is a common side effect of clozapine but is not as urgent as fever. Blurred vision (Choice B) and dry mouth (Choice D) are side effects of clozapine but are not indicative of a life-threatening condition like agranulocytosis.
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