ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?
- A. Place the client on cardiac monitoring
- B. Monitor the client's oxygen saturation level
- C. Provide standby assistance when getting out of bed
- D. Encourage foods high in potassium
Correct answer: C
Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.
2. A nurse is teaching a client with mild persistent asthma who has been prescribed montelukast. Which statement by the nurse is appropriate?
- A. This medication can be used during an acute asthma attack.
- B. This medication should be taken before exercise.
- C. You can take this medication for 10 days, then discontinue.
- D. This medication helps decrease swelling and mucus production.
Correct answer: D
Rationale: The correct answer is D: 'This medication helps decrease swelling and mucus production.' Montelukast is used for long-term asthma management as it helps reduce inflammation and mucus production in the airways. It is not appropriate for acute asthma attacks. Choice A is incorrect because montelukast is not a rescue medication for acute attacks. Choice B is incorrect because montelukast is not specifically taken before exercise. Choice C is incorrect because montelukast is usually taken regularly, not just for a short duration.
3. A nurse is caring for a client with hepatic encephalopathy. Which food selection indicates an understanding of dietary teaching?
- A. Cottage cheese
- B. Tuna salad
- C. Rice with black beans
- D. Three-egg omelet
Correct answer: C
Rationale: The correct answer is C: 'Rice with black beans.' Clients with hepatic encephalopathy should limit animal proteins due to their high ammonia content, which can exacerbate symptoms. Plant-based proteins like beans are preferred as they help reduce ammonia levels. Choices A, B, and D contain animal proteins that are not ideal for clients with hepatic encephalopathy.
4. A nurse is providing discharge teaching to a client who has a prescription for home oxygen. Which information should the nurse teach?
- A. Use a humidifier with the oxygen
- B. Wear cotton socks when the oxygen is in use
- C. Avoid all types of smoking materials
- D. Use a nasal cannula during meals
Correct answer: B
Rationale: The correct answer is B: 'Wear cotton socks when the oxygen is in use.' This information is important as wearing cotton socks helps prevent static electricity, which can pose a fire risk when oxygen is in use. Choice A is incorrect as using a humidifier with oxygen is not necessary for all clients and may not be part of standard discharge teaching. Choice C is incorrect as it is a common safety measure to avoid all types of smoking materials when using oxygen. Choice D is incorrect as using a nasal cannula during meals is not specifically related to the safety concerns associated with home oxygen use.
5. A client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery is being assisted by a nurse. Which of the following statements should the nurse make?
- A. You should not worry about it
- B. The surgeon will answer your questions before surgery
- C. It’s too late to cancel the surgery
- D. You need to trust the medical team
Correct answer: B
Rationale: The correct answer is B because the nurse should encourage the client to express concerns and ensure that the surgeon addresses any questions prior to the procedure. Choice A is incorrect as it dismisses the client's worries. Choice C is incorrect because it does not respect the client's autonomy in decision-making. Choice D is incorrect as it does not address the client's doubts directly or provide reassurance.
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