ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which action should the nurse take if the client develops toxicity?
- A. Administer calcium gluconate IV
- B. Increase the magnesium sulfate infusion
- C. Administer IV fluids
- D. Administer hydralazine
Correct answer: A
Rationale: In cases of magnesium sulfate toxicity, administering calcium gluconate IV is crucial as it is the antidote for magnesium sulfate. Calcium gluconate helps reverse the effects of magnesium sulfate, especially when signs of toxicity like respiratory depression or loss of reflexes occur. Increasing the magnesium sulfate infusion would worsen toxicity. Administering IV fluids may be beneficial for hydration but does not address magnesium sulfate toxicity. Hydralazine is used to manage hypertension, not magnesium sulfate toxicity.
2. A healthcare professional is assessing a client for signs of stroke. Which of the following should the healthcare professional look for?
- A. Slurred speech
- B. Increased appetite
- C. Elevated heart rate
- D. Hyperactivity
Correct answer: A
Rationale: Corrected Question: A healthcare professional is assessing a client for signs of stroke. Slurred speech is a common sign of stroke and should be assessed immediately. Choices B, C, and D are incorrect because increased appetite, elevated heart rate, and hyperactivity are not typical signs of a stroke.
3. A client who is 28 weeks pregnant and has preeclampsia is being cared for by a nurse. Which of the following is the priority assessment?
- A. Level of consciousness
- B. Deep tendon reflexes
- C. Blood pressure
- D. Urinary output
Correct answer: C
Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption. Assessing the blood pressure helps in monitoring the severity of the preeclampsia and guiding appropriate interventions. While monitoring the client's level of consciousness, deep tendon reflexes, and urinary output are important, they are secondary assessments in the context of preeclampsia.
4. A client has been prescribed amlodipine for hypertension. Which of the following adverse effects should the nurse instruct the client to report?
- A. Dry cough
- B. Dizziness
- C. Rash
- D. Headache
Correct answer: B
Rationale: The correct answer is B: 'Dizziness.' Amlodipine, a calcium channel blocker used for hypertension, can cause dizziness due to its blood pressure-lowering effects. It is crucial for clients to report dizziness to their healthcare provider as it may indicate hypotension. Dry cough (choice A) is more commonly associated with ACE inhibitors, rash (choice C) may be seen in allergic reactions, and headache (choice D) is a less common side effect of amlodipine.
5. A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following actions should the nurse take?
- A. Administer the TPN solution separately from 0.9% sodium chloride
- B. Check for an allergy to eggs
- C. Discuss the TPN solution with the client
- D. Monitor for hypoglycemia
Correct answer: B
Rationale: The correct action for the nurse to take when preparing to administer TPN with fat supplements is to check for an allergy to eggs. The lipid emulsion in TPN often contains egg phospholipids, so screening for egg allergies is crucial to prevent any adverse reactions. Option A is incorrect because TPN should not be piggybacked with 0.9% sodium chloride to avoid any interactions or dilution of the TPN solution. Option C is incorrect as discussing the TPN solution with the client is not the priority when preparing to administer it. Option D is incorrect as monitoring for hypoglycemia, although important in TPN administration, is not specifically related to the addition of fat supplements.
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