ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A client with a history of asthma is being cared for by a nurse. Which of the following should the nurse monitor?
- A. Heart rate
- B. Respiratory status
- C. Blood glucose levels
- D. Liver function
Correct answer: B
Rationale: The correct answer is B: Respiratory status. When caring for a client with asthma, it is essential to monitor their respiratory status to detect any changes in breathing or signs of airway obstruction. Monitoring heart rate (choice A) may be important in some situations but is not the priority when managing asthma. Blood glucose levels (choice C) and liver function (choice D) are not directly related to asthma and would not be the primary focus of monitoring for a client with this condition.
2. A client with diabetes mellitus is receiving education on foot care. Which of the following instructions should the nurse include?
- A. Apply lotion between the toes.
- B. Cut toenails straight across.
- C. Use a heating pad to warm the feet.
- D. Soak feet in warm water daily.
Correct answer: B
Rationale: The correct answer is B: Cut toenails straight across. This instruction is vital for clients with diabetes as it helps prevent ingrown toenails and infections, reducing the risk of foot ulcers. Applying lotion between the toes (choice A) should be avoided as it can create a moist environment prone to fungal infections. Using a heating pad (choice C) can lead to burns or injuries due to reduced sensation common in diabetes. Soaking feet in warm water daily (choice D) can also increase the risk of skin breakdown and should be avoided.
3. A nurse is preparing to administer a dose of escitalopram. Which of the following should the nurse assess first?
- A. Mood changes
- B. Blood pressure
- C. Heart rate
- D. Liver function
Correct answer: A
Rationale: The correct answer is to assess for mood changes. When administering escitalopram, it is crucial to evaluate mood changes first because the medication may take some time to demonstrate its full effects on the patient's mood. Assessing blood pressure, heart rate, or liver function is not the priority when administering escitalopram, as these parameters are not directly impacted acutely by this medication.
4. A nurse is preparing to administer medications to a client who is NPO and has an NG tube for suction. Which of the following actions should the nurse take?
- A. Mix medications with enteral feedings.
- B. Clamp the NG tube for 30 minutes after medication administration.
- C. Insert medications directly into the NG tube without dilution.
- D. Connect the NG tube to continuous suction after medication.
Correct answer: B
Rationale: The correct action for the nurse to take when administering medications to a client with an NG tube for suction who is NPO is to clamp the NG tube for 30 minutes after medication administration. This is done to allow for proper absorption of the medications before resuming suction. Choice A is incorrect because medications should not be mixed with enteral feedings as it may affect the drug's effectiveness. Choice C is incorrect as medications should not be inserted directly into the NG tube without dilution, as this can cause clogging or affect the tube. Choice D is incorrect because connecting the NG tube to continuous suction after medication administration can interfere with the absorption of the medications.
5. A client is at high risk for iron deficiency anemia. Which of the following foods should the nurse instruct the client to increase in their diet?
- A. Yogurt
- B. Apples
- C. Raisins
- D. Cheddar cheese
Correct answer: C
Rationale: The correct answer is C: Raisins. Raisins are a good source of iron, which can help prevent or address iron deficiency anemia. Yogurt (Choice A) and cheddar cheese (Choice D) are not significant sources of iron. While apples (Choice B) are a healthy fruit, they do not contain as much iron as raisins.
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