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 client undergoing radiation therapy is being taught about skin care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will use a heating pad to soothe the skin
- B. I will avoid using perfumed lotions on the treated area
- C. I will apply cold compresses to the area
- D. I will scrub the area daily with soap and water
Correct answer: B
Rationale: The correct answer is B because avoiding perfumed lotions is important to prevent skin irritation after radiation therapy. Using a heating pad (A) can further damage the skin, applying cold compresses (C) may not be recommended, and scrubbing the area daily with soap and water (D) can be too harsh on the skin, leading to further irritation and damage.
3. Which statement best describes direct contact as a mode of pathogen transmission?
- A. Transmission through large aerosols produced by sneezing or coughing
- B. Transfer of an infectious agent by suspended air particles from a reservoir to a host
- C. Transmission of infectious agents carried by dust
- D. Transmission through skin-to-skin contact or body fluids
Correct answer: D
Rationale: Direct contact transmission occurs when pathogens are spread through skin-to-skin contact or body fluids. This mode of transmission includes activities like touching, kissing, or sexual contact where infectious agents can pass directly from one person to another. It does not involve large aerosols, suspended air particles, or dust as carriers of the pathogen.
4. Which of the following is a key consideration when caring for a client with heart failure on fluid restriction?
- A. Encourage the client to drink more fluids to stay hydrated
- B. Weigh the client daily to monitor fluid status
- C. Limit the client's intake of fruits and vegetables
- D. Monitor the client's fluid intake only during meals
Correct answer: B
Rationale: When caring for a client with heart failure on fluid restriction, weighing the client daily is crucial to monitor fluid balance accurately. This helps healthcare providers assess if the client is retaining excess fluids, which can worsen heart failure. Encouraging the client to drink more fluids (choice A) contradicts the goal of fluid restriction. Limiting intake of fruits and vegetables (choice C) is not a specific guideline for managing fluid restriction in heart failure. Monitoring fluid intake only during meals (choice D) is insufficient as fluid balance needs to be monitored consistently throughout the day.
5. When using the Ballard gestational assessment tool on a newborn, which of the following tests should be performed after the first hour of birth, allowing the newborn to recover from the stress of birth?
- A. Arm recoil
- B. Square window sign
- C. Scarf sign
- D. Popliteal angle
Correct answer: A
Rationale: The correct answer is Arm recoil. Arm recoil is slower in healthy but fatigued newborns after birth, making it best elicited after the first hour of birth when the baby has had time to recover from the stress of birth. This assessment helps evaluate neuromuscular maturity in newborns and is more accurate when performed after the initial recovery period. The other choices, Square window sign, Scarf sign, and Popliteal angle, are not specifically assessed using the Ballard gestational assessment tool and do not relate to the recovery period after birth.
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