ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A client is receiving enoxaparin for the prevention of DVT. Which of the following is an appropriate action by the nurse?
- A. Expel any air bubbles from the prefilled syringe
- B. Massage the injection site to aid in absorption of the medication
- C. Inject the medication into the lateral abdominal wall
- D. Administer an NSAID for injection site discomfort
Correct answer: C
Rationale: The correct answer is to inject enoxaparin into the lateral abdominal wall for subcutaneous absorption. This site is commonly used for administering this type of medication. Expelling air bubbles from the syringe is not necessary and may result in a reduced dose being administered. Massaging the injection site is not recommended as it can lead to bruising or irritation. Administering an NSAID for injection site discomfort is not indicated as discomfort at the injection site is usually minimal and self-limiting.
2. A nurse is caring for a client who has a urinary tract infection (UTI) and is prescribed ciprofloxacin. Which of the following client statements indicates a need for further teaching?
- A. I will stop taking the medication when I feel better.
- B. I will avoid caffeine while taking this medication.
- C. I will wear sunscreen when going outside.
- D. I will drink plenty of fluids while on this medication.
Correct answer: A
Rationale: Clients should be instructed to complete the entire course of antibiotics, even if they start feeling better, to prevent antibiotic resistance and recurrence of infection.
3. A nurse is caring for a client receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?
- A. Stop the infusion.
- B. Slow the infusion.
- C. Apply a warm compress to the site.
- D. Apply a cold compress to the site.
Correct answer: A
Rationale: Corrected Rationale: If infiltration is suspected, the nurse should immediately stop the dopamine infusion to prevent further damage to the surrounding tissue. Choice A is the correct answer because continuing the infusion can lead to tissue damage and compromise the client's care. Slowing the infusion (Choice B) is not sufficient to prevent harm and may still cause damage. Applying a warm compress (Choice C) or a cold compress (Choice D) is not the recommended action for infiltration; stopping the infusion is crucial to prevent complications.
4. 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.
5. A nurse is planning care for an adolescent client with chronic renal failure. Which action should the nurse include?
- A. Encourage a diet high in calcium
- B. Provide a diet high in potassium
- C. Ensure increased fluid intake
- D. Restrict protein intake to the RDA
Correct answer: D
Rationale: In chronic renal failure, it is essential to restrict protein intake to the Recommended Dietary Allowance (RDA) to reduce the accumulation of waste products that the kidneys can no longer effectively eliminate. Choices A, B, and C are incorrect because in chronic renal failure, high calcium, high potassium, and increased fluid intake can further strain the kidneys and worsen the condition.
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