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 caring for a client with a new prescription for metoprolol. Which of the following should the nurse monitor?
- A. Blood pressure
- B. Liver function
- C. Serum potassium levels
- D. Blood glucose
Correct answer: A
Rationale: Corrected Rationale: Metoprolol is a beta-blocker commonly used to treat conditions like hypertension and angina. As a beta-blocker, it primarily affects the cardiovascular system by reducing heart rate and blood pressure. Therefore, the nurse should monitor the client's blood pressure regularly to assess the drug's effectiveness and ensure that it is within the therapeutic range. Monitoring liver function, serum potassium levels, or blood glucose is not typically required for clients taking metoprolol, as its primary impact is on the heart and blood vessels, making choice A the most appropriate monitoring parameter.
3. A client with cholecystitis has been prescribed a low-fat diet. Which of the following meal selections by the client indicates understanding of the education?
- A. Roast beef with gravy, mashed potatoes, ice cream
- B. Macaroni and cheese, salad, pudding
- C. Creamed chicken on a roll with peas
- D. Roast turkey, rice pilaf, green beans
Correct answer: D
Rationale: The correct answer is D. Roast turkey is a lean protein option suitable for a low-fat diet. Rice pilaf and green beans are also low in fat. Choices A, B, and C contain high-fat ingredients like gravy, cheese, cream, and ice cream, which are not suitable for a low-fat diet.
4. A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this finding?
- A. Papule
- B. Vesicle
- C. Macule
- D. Nodule
Correct answer: C
Rationale: The correct term the nurse should use to document this finding is 'Macule.' A macule is a flat, nonpalpable skin lesion that is smaller than 1 cm in diameter. In this case, the lesion described is less than 0.5 cm, making it appropriate to classify it as a macule. 'Papule' (Choice A) refers to a solid, elevated skin lesion, 'Vesicle' (Choice B) is a small fluid-filled blister, and 'Nodule' (Choice D) is a solid, elevated skin lesion that is larger and deeper than a papule, none of which accurately describe the lesion in question.
5. A healthcare professional is teaching a client about reducing the risk of urinary tract infections (UTIs). Which factor increases the risk of UTI?
- A. Wearing underwear with a cotton crotch
- B. Wiping from front to back
- C. Using perfumed toilet paper
- D. Urinating after intercourse
Correct answer: C
Rationale: Using perfumed toilet paper can irritate the urinary tract and increase the risk of UTI, so it should be avoided. Wearing underwear with a cotton crotch (Choice A) is a preventive measure as cotton allows for better air circulation and reduces moisture, lowering the risk of UTIs. Wiping from front to back (Choice B) helps prevent the introduction of bacteria from the anal region to the urinary tract. Urinating after intercourse (Choice D) can help flush out bacteria introduced during sexual activity, thereby reducing the risk of UTIs.
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