ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is caring for a client who is taking warfarin. The nurse notes that the client has a new prescription for amoxicillin. Which of the following laboratory tests should the nurse monitor closely?
- A. Serum potassium
- B. Prothrombin time (PT)
- C. Serum sodium
- D. Blood glucose
Correct answer: B
Rationale: The correct answer is B: Prothrombin time (PT). Amoxicillin can potentiate the effects of warfarin, increasing the risk of bleeding. Monitoring the prothrombin time (PT) is crucial in this situation to assess the client's clotting ability. Choices A, C, and D are incorrect because amoxicillin's interaction with warfarin does not directly impact serum potassium, serum sodium, or blood glucose levels.
2. A healthcare professional is reviewing the health history of an older adult who has a hip fracture. What is a risk factor for developing pressure injuries?
- A. Dehydration
- B. Urinary incontinence
- C. Poor nutrition
- D. Poor tissue perfusion
Correct answer: B
Rationale: Urinary incontinence is a risk factor for developing pressure injuries due to prolonged skin exposure to moisture and irritants. Dehydration (choice A) can contribute to skin dryness but is not a direct risk factor for pressure injuries. Poor nutrition (choice C) can affect wound healing but is not specifically linked to pressure injuries. Poor tissue perfusion (choice D) can increase the risk of tissue damage but is not as directly associated with pressure injuries as urinary incontinence.
3. A healthcare professional is preparing to administer morphine for severe pain. What is the priority assessment the professional should make before administration?
- A. Blood pressure
- B. Respiratory rate
- C. Heart rate
- D. Temperature
Correct answer: B
Rationale: Before administering morphine, the priority assessment the healthcare professional should make is the client's respiratory rate. Morphine can cause respiratory depression, so assessing the respiratory rate is crucial to prevent any potential complications. Assessing blood pressure, heart rate, and temperature are important as well, but they are not the priority when administering morphine for severe pain.
4. A client with Ménière’s disease is experiencing episodes of vertigo. Which of the following interventions should the nurse include in the plan?
- A. Encourage bed rest
- B. Restrict fluid intake to the morning hours
- C. Administer aspirin
- D. Provide a low sodium diet
Correct answer: D
Rationale: The correct intervention for a client with Ménière’s disease experiencing vertigo is to provide a low sodium diet. Limiting sodium helps to reduce fluid retention, which in turn decreases the manifestations of Ménière’s disease. Encouraging bed rest (Choice A) may be necessary during acute episodes but is not a long-term solution. Restricting fluid intake (Choice B) to the morning hours does not specifically address the underlying issue of fluid retention associated with Ménière’s disease. Administering aspirin (Choice C) is not recommended for Ménière’s disease as it can worsen symptoms.
5. While receiving a change of shift report on a group of clients, which patient should the nurse assess first?
- A. The client who has a fractured femur and reports sharp chest pain.
- B. The client who has a fever and is receiving antibiotics.
- C. The client who has a urinary tract infection and reports pain with urination.
- D. The client who is scheduled for surgery in the afternoon.
Correct answer: A
Rationale: The nurse should assess the client with a fractured femur and sharp chest pain first. Sharp chest pain in this client may indicate a pulmonary embolism, a life-threatening condition requiring immediate attention. The other options describe important patient conditions but do not pose an immediate threat to life like a potential pulmonary embolism does.
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