ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?
- A. Urinary output of 40 mL/hr
- B. Respiratory rate of 10 breaths per minute
- C. Absent deep tendon reflexes
- D. Blood pressure of 150/90 mm Hg
Correct answer: B
Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention. Urinary output of 40 mL/hr (Choice A) is within the normal range for a client receiving magnesium sulfate. Absent deep tendon reflexes (Choice C) are an expected finding due to the medication's effect on neuromuscular excitability. A blood pressure of 150/90 mm Hg (Choice D) is slightly elevated but not a priority concern compared to severe respiratory depression.
2. A client is prescribed tramadol for pain management. Which of the following should the nurse educate the client about?
- A. It is a non-opioid analgesic
- B. It can cause sedation
- C. It has no risk for dependence
- D. It can be taken as needed
Correct answer: B
Rationale: The correct answer is B. Tramadol can cause sedation, so the nurse should educate the client about this potential side effect. Choice A is incorrect because tramadol is actually an opioid analgesic. Choice C is incorrect as tramadol does carry a risk for dependence, especially with prolonged use. Choice D is not entirely accurate as tramadol is usually prescribed on a scheduled basis rather than as needed.
3. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which type of immunity?
- A. Innate immunity
- B. Passive immunity
- C. Acquired immunity
- D. Natural immunity
Correct answer: C
Rationale: The correct answer is C: Acquired immunity. Acquired immunity occurs when an individual is given a vaccine or immunization to develop antibodies. This type of immunity is specific and develops after exposure to an antigen. Innate immunity (choice A) is the body's natural defense system present at birth. Passive immunity (choice B) is temporary immunity passed from one individual to another. Natural immunity (choice D) refers to immunity that is not gained through medical intervention or deliberate exposure.
4. While caring for a client receiving patient-controlled analgesia (PCA), which of the following interventions should the nurse take?
- A. Encourage the client to use the PCA before dressing changes.
- B. Monitor the client's respiratory status.
- C. Provide oxygen therapy to the client as needed.
- D. Ensure the PCA pump is functioning properly.
Correct answer: A
Rationale: Corrected Rationale: The nurse should encourage the client to use the PCA pump before activities like dressing changes, which are likely to cause pain, to ensure effective pain management. Monitoring the client's respiratory status (Choice B) is important but not the priority in this scenario. Providing oxygen therapy (Choice C) is not a routine intervention for all clients on PCA unless specifically indicated. Ensuring the PCA pump is functioning properly (Choice D) is essential, but encouraging the client to use the PCA before painful activities takes precedence to manage pain effectively.
5. A nurse is educating a patient about their new prescription for a statin medication. What should the nurse advise the patient to avoid while taking this medication?
- A. Drinking grapefruit juice
- B. Consuming high-protein meals
- C. Exercising regularly
- D. Taking the medication in the morning
Correct answer: A
Rationale: The correct answer is A: Drinking grapefruit juice. Grapefruit juice can increase the risk of statin toxicity by interfering with the enzyme that metabolizes statin medications, leading to higher drug levels in the body. This interaction can potentially cause adverse effects. Therefore, patients should be advised to avoid consuming grapefruit juice while taking statins. Choices B, C, and D are incorrect. Consuming high-protein meals, exercising regularly, and taking the medication in the morning are not contraindicated while on statin therapy. In fact, following a healthy diet, engaging in physical activity, and taking the medication at a consistent time each day can be beneficial for patients prescribed statins.
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