ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate via IV infusion. Which of the following findings indicates magnesium toxicity?
- A. Blood glucose of 150 mg/dL
- B. Urine output of 20 mL/hour
- C. Systolic blood pressure of 140 mm Hg
- D. BUN 20 mg/dL
Correct answer: B
Rationale: The correct answer is B. A urine output of 20 mL/hour is a sign of magnesium toxicity because decreased urine output can lead to accumulation of magnesium. Choices A, C, and D are not indicators of magnesium toxicity. Elevated blood glucose, high systolic blood pressure, and normal BUN levels do not specifically point towards magnesium toxicity.
2. A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which of the following client information should the nurse identify as a contributing factor?
- A. The client has a history of recurring bowel inflammation.
- B. The client has recently increased their exercise regimen.
- C. The client is taking herbal supplements.
- D. The client is experiencing increased stress.
Correct answer: A
Rationale: The correct answer is A. Recurring bowel inflammation can decrease gastrointestinal motility, affecting the absorption of oral medications. This can lead to decreased effectiveness of the arthritis medication. Choice B is incorrect because increasing exercise would not typically impact the absorption of arthritis medication. Choice C is incorrect as herbal supplements may not directly affect the absorption of conventional arthritis medication. Choice D is also incorrect as stress, while it can impact overall health, is less likely to directly affect the effectiveness of arthritis medication compared to gastrointestinal issues.
3. A client who is at 24 weeks of gestation is being taught about the signs of preterm labor. Which of the following should the nurse include?
- A. Sudden weight loss
- B. Regular contractions
- C. Shortness of breath
- D. Vaginal spotting
Correct answer: B
Rationale: The correct answer is B: Regular contractions. Regular contractions before 37 weeks of gestation are a significant sign of preterm labor. It is essential for clients to be aware of this symptom and report it promptly to their healthcare provider. Choices A, C, and D are incorrect because sudden weight loss, shortness of breath, and vaginal spotting are not typical signs of preterm labor. Teaching clients about the specific signs of preterm labor can help in early detection and intervention, ultimately improving outcomes for both the client and the baby.
4. A nurse is completing a dietary assessment for a client who observes kosher dietary practices. Which of the following behaviors should the nurse expect?
- A. Leavened bread may be eaten during Passover
- B. Shellfish is commonly consumed in the diet
- C. Meat and dairy products are eaten separately
- D. Fasting from meat occurs during Hanukkah
Correct answer: C
Rationale: The correct answer is C: 'Meat and dairy products are eaten separately.' In kosher dietary practices, it is essential to keep meat and dairy products separate. Mixing meat and dairy is prohibited, and there are specific guidelines for the preparation and consumption of each. Choices A, B, and D are incorrect. Choice A is wrong because leavened bread is not eaten during Passover in kosher practices. Choice B is incorrect as shellfish is not consumed in a kosher diet. Choice D is also inaccurate as fasting from meat does not occur during Hanukkah in kosher dietary practices.
5. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?
- A. Aspirate before injecting
- B. Massage the site after injecting
- C. Administer the injection in the abdomen
- D. Inject at a 90-degree angle
Correct answer: C
Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication in the abdomen subcutaneously. This route ensures proper absorption of the medication. Aspiration is not necessary before injecting enoxaparin as it is a subcutaneous injection, not an intramuscular injection. Massaging the site after injecting should be avoided to prevent bruising. Enoxaparin injections are typically given at a 45 to 90-degree angle, not necessarily at a strict 90-degree angle.
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