ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A client is receiving IV moderate sedation with midazolam and has a respiratory rate of 9/min. What should the nurse do?
- A. Place the client in a prone position
- B. Implement positive pressure ventilation
- C. Perform nasopharyngeal suctioning
- D. Administer flumazenil
Correct answer: D
Rationale: The correct answer is D: Administer flumazenil. Flumazenil is the reversal agent for midazolam, a benzodiazepine, and should be administered to counteract respiratory depression. Placing the client in a prone position (choice A) could further compromise their breathing. Implementing positive pressure ventilation (choice B) is not indicated as the first step when dealing with respiratory depression due to sedation. Performing nasopharyngeal suctioning (choice C) is not appropriate in this situation where the client is experiencing respiratory depression due to medication sedation.
2. The client is receiving intravenous heparin for the treatment of a pulmonary embolism. Which medication should the nurse ensure is readily available?
- A. Protamine sulfate
- B. Vitamin K
- C. Calcium gluconate
- D. Magnesium sulfate
Correct answer: A
Rationale: Protamine sulfate is the antidote for heparin, used to reverse its anticoagulant effects. It should be readily available in case of bleeding complications, as it can rapidly neutralize the effects of heparin and prevent excessive bleeding. Vitamin K is used to reverse the effects of warfarin, not heparin (Choice B). Calcium gluconate is used to treat calcium deficiencies, not indicated for heparin therapy (Choice C). Magnesium sulfate is used for conditions like preeclampsia and eclampsia, not for reversing heparin effects (Choice D).
3. To maintain the cleanliness of the bag and its contents, what should the nurse do?
- A. Wash their hands before and after providing care to family members
- B. Use only items from the bag when caring for family members
- C. Wear an apron to protect their uniform and fold it with the right side out before returning it to the bag
- D. Fold the lining on which the bag was placed at the end of the visit, ensuring the contaminated side is facing outward
Correct answer: A
Rationale: The most crucial step in maintaining cleanliness when caring for family members and handling the bag and its contents is to wash the nurse's hands before and after providing care. This practice helps prevent the spread of germs and maintains proper hygiene standards, reducing the risk of contamination. Washing hands is a fundamental infection control measure that all healthcare professionals should adhere to in their daily practice.
4. Which intervention is most appropriate to promote the self-esteem of a patient with severe depression?
- A. Encouraging the patient to spend time alone for self-reflection.
- B. Involving the patient in simple, achievable activities to ensure success.
- C. Allowing the patient to rest and avoid responsibilities.
- D. Providing frequent reassurances and compliments.
Correct answer: B
Rationale: Involving the patient in simple, achievable activities is a constructive approach to promote self-esteem by fostering a sense of accomplishment and success. This method encourages positive reinforcement and helps the patient regain confidence and self-worth, which are essential in managing depression. Choice A could potentially lead to rumination and worsen depressive symptoms. Choice C might reinforce avoidance behaviors and hinder progress. Choice D, while supportive, may not address the core need for building self-esteem through personal achievements.
5. A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for the administration of this medication?
- A. Heart disease
- B. Cervical dilation of 2 cm
- C. Gestational age of 34 weeks
- D. Allergy to penicillin
Correct answer: A
Rationale: The correct answer is A, heart disease. Terbutaline is contraindicated in clients with heart disease because it can lead to tachycardia and other cardiac complications due to its beta-agonist properties. Choice B, cervical dilation of 2 cm, is not a contraindication for terbutaline administration in preterm labor. Choice C, gestational age of 34 weeks, does not contraindicate the use of terbutaline for preterm labor. Choice D, allergy to penicillin, is not related to the contraindications of terbutaline.
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