ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A client at 28 weeks of gestation is experiencing preterm labor. Which of the following medications should the nurse plan to administer?
- A. Oxytocin
- B. Nifedipine
- C. Dinoprostone
- D. Misoprostol
Correct answer: B
Rationale: Nifedipine is the correct choice because it is a calcium channel blocker that helps relax the uterus and stop preterm labor. Oxytocin (Choice A) is used to induce labor, not to stop preterm labor. Dinoprostone (Choice C) and Misoprostol (Choice D) are prostaglandins used to induce labor and ripen the cervix, not to stop preterm labor.
2. When teaching a client with a new diagnosis of heart failure about dietary management, which of the following statements should the nurse include?
- A. Increase your intake of sodium-rich foods.
- B. Decrease your intake of sodium-rich foods.
- C. Avoid foods that contain lactose.
- D. Increase your intake of dairy products.
Correct answer: B
Rationale: The correct answer is to decrease the intake of sodium-rich foods. Sodium restriction is crucial in managing heart failure as it helps to reduce fluid retention and alleviate symptoms. Excessive sodium intake can lead to fluid buildup in the body, worsening heart failure. Therefore, advising the client to decrease sodium-rich foods is essential for their overall health and management of the condition. Choices A, C, and D are incorrect. Increasing intake of sodium-rich foods (Choice A) would worsen fluid retention and heart failure symptoms. Avoiding foods that contain lactose (Choice C) is not directly related to heart failure management through sodium restriction. Increasing intake of dairy products (Choice D) may not be suitable for all heart failure patients, especially if they need to limit saturated fats or cholesterol in their diet.
3. A client with a permanent spinal cord injury is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?
- A. “I would like to play wheelchair basketball. When I get stronger, I think I’ll look for a league.”
- B. “I’m glad I’ll only be in this wheelchair temporarily. I can’t wait to get back to running.”
- C. “I’m so upset that this happened to me. What did I do to deserve this, and why am I not getting better?”
- D. “I feel like I’ll never be able to do anything that I want to again. All I am is a burden to my family.”
Correct answer: A
Rationale: Choice A is the correct answer. This statement demonstrates effective coping as the client is showing acceptance of their disability and planning for the future with realistic goals. Choice B reflects denial of the permanent disability by stating that they will only be in a wheelchair temporarily. Choice C shows distress and a lack of acceptance by questioning why the injury happened and why they are not improving. Choice D indicates feelings of hopelessness and being a burden, which are not signs of effective coping.
4. A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?
- A. Lower back pain
- B. Shortness of breath
- C. Decreased fetal movement
- D. Nausea and vomiting
Correct answer: A
Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery. Shortness of breath (Choice B), decreased fetal movement (Choice C), and nausea and vomiting (Choice D) can be common during pregnancy but are not typically associated with preterm labor. While they should be monitored, they are not immediate signs of concern for preterm labor.
5. A nurse in a pediatric clinic is collecting data from a school-age child whose injuries are inconsistent with the parent's stated cause. Which of the following actions should the nurse take?
- A. Provide teaching to the parents
- B. Report suspected abuse to the appropriate agency
- C. Document the injuries and monitor the child
- D. Counsel the parents privately
Correct answer: B
Rationale: In cases where a child's injuries are inconsistent with the parent's stated cause, it raises concerns about possible abuse. The correct action for the nurse in this situation is to report suspected abuse to the appropriate agency. This is a legal and ethical obligation for healthcare professionals when they suspect child abuse. Providing teaching to the parents (Choice A) may not address the immediate safety concerns of the child. Documenting the injuries and monitoring the child (Choice C) is important but reporting suspected abuse takes precedence to ensure the child's safety. Counseling the parents privately (Choice D) may not be effective if abuse is suspected, as the primary focus should be on protecting the child.