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. A client with osteoporosis is being taught by a nurse about dietary changes. Which of the following food choices should the nurse recommend to promote bone health?
- A. Leafy green vegetables
- B. Red meat
- C. Fortified orange juice
- D. Whole grains
Correct answer: C
Rationale: The correct answer is C: Fortified orange juice. Fortified orange juice is often supplemented with calcium and vitamin D, both of which are essential for bone health and the prevention of osteoporosis. Leafy green vegetables (choice A) are good for overall health but may not provide sufficient calcium for bone health. Red meat (choice B) is a source of protein but is not a primary source of calcium. Whole grains (choice D) are beneficial for fiber intake but do not contain significant amounts of calcium or vitamin D necessary for bone health.
3. When reinforcing teaching about self-care with a patient who has pelvic inflammatory disease and does not speak English, what action by the nurse is appropriate?
- A. Provide written instructions in English.
- B. Use family members as translators.
- C. Seek assistance from a facility-approved interpreter.
- D. Use online translation tools.
Correct answer: C
Rationale: When communicating with a patient who does not speak English, it is crucial to seek assistance from a facility-approved interpreter. Using family members as translators can lead to inaccuracies, breaches in confidentiality, and discomfort for the patient. Online translation tools may not provide accurate or context-specific translations, which can result in misunderstandings. Providing written instructions in English would not be effective if the patient does not understand the language.
4. When teaching about safety risks for adolescents, what should be included?
- A. Adolescents are more likely to follow rules
- B. Peer influence to participate in high-risk behaviors can lead to injury
- C. Most injuries occur during sports activities
- D. Adolescents are aware of the dangers of substance use
Correct answer: B
Rationale: When educating about safety risks for adolescents, it is crucial to address the impact of peer influence on engaging in high-risk behaviors, which can result in injuries. Choice A is incorrect because adolescents are known to sometimes take risks and not always follow rules. Choice C is incorrect as injuries among adolescents can also happen outside of sports activities. Choice D is incorrect as adolescents may not always be fully aware of the dangers of substance use.
5. A nurse enters a client’s room and sees smoke coming from the trash can. Which action should the nurse take first?
- A. Extinguish the fire
- B. Activate the fire alarm
- C. Evacuate the room
- D. Call the client’s family
Correct answer: C
Rationale: In a fire emergency, the priority for the nurse is to ensure safety. The correct first action is to evacuate the room, following the RACE protocol, which stands for Rescue, Alarm, Contain, and Extinguish/Evacuate. Activating the fire alarm alerts others, extinguishing the fire can escalate the situation if not done correctly, and calling the client's family is not a priority in this emergency scenario.
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