ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A nurse is caring for a client with a new prescription for lisinopril. Which of the following should the nurse monitor?
- A. Blood pressure
- B. Liver function
- C. Serum potassium levels
- D. Heart rate
Correct answer: A
Rationale: Corrected Rationale: Lisinopril is an ACE inhibitor commonly used to lower blood pressure. Monitoring blood pressure is crucial when initiating this medication to assess its effectiveness and potential side effects related to blood pressure regulation. Liver function monitoring is not typically required with lisinopril. While lisinopril can affect potassium levels, it is not the primary parameter to monitor when starting this medication. Heart rate monitoring is not a routine requirement when initiating lisinopril therapy.
2. A client with heart failure and a new prescription for furosemide is receiving teaching from a nurse. Which of the following instructions should the nurse include?
- A. Avoid foods high in magnesium
- B. Take furosemide with food
- C. Eat foods that are rich in potassium
- D. Expect a decrease in blood pressure
Correct answer: C
Rationale: The correct instruction the nurse should include is to advise the client to eat foods that are rich in potassium. Furosemide is a loop diuretic that can cause the loss of potassium, leading to hypokalemia. Eating foods high in potassium can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide does not directly interact with magnesium. Choice B is incorrect because furosemide is usually taken in the morning to prevent nighttime diuresis. Choice D is incorrect because furosemide is a diuretic that typically leads to a decrease in blood pressure rather than an increase.
3. While caring for a client in active labor, a nurse notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?
- A. Change the client's position
- B. Palpate the uterus to assess for tachysystole
- C. Increase the client's IV infusion rate
- D. Administer oxygen at 10 L/min via nonrebreather mask
Correct answer: A
Rationale: The correct initial action for the nurse to take is to change the client's position. This intervention can alleviate pressure on the umbilical cord, potentially improving fetal oxygenation and addressing the underlying cause of late decelerations. Palpating the uterus to assess for tachysystole or increasing the IV infusion rate are not the first-line interventions for addressing late decelerations. Administering oxygen at a high flow rate via a nonrebreather mask may be necessary but is not the priority action in this situation.
4. A nurse is assessing a client with chronic kidney disease. Which of the following should the nurse monitor for?
- A. Hyperkalemia
- B. Hypercalcemia
- C. Hypoglycemia
- D. Hyponatremia
Correct answer: A
Rationale: The correct answer is A: Hyperkalemia. Clients with chronic kidney disease are at risk for hyperkalemia due to impaired potassium excretion. In chronic kidney disease, the kidneys are unable to effectively excrete potassium, leading to its accumulation in the blood. Hypercalcemia (Choice B) is not typically associated with chronic kidney disease. Hypoglycemia (Choice C) refers to low blood sugar levels and is not directly related to chronic kidney disease. Hyponatremia (Choice D) is a condition characterized by low sodium levels and is not a typical concern in chronic kidney disease.
5. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?
- A. Response to pain medication
- B. Review of ongoing discharge plan
- C. Recent physical changes
- D. All of the above
Correct answer: D
Rationale: When preparing a client for transfer to another unit, the nurse should include all the findings mentioned in the choices in the transfer report. It is crucial to document the client's response to pain medication as it helps the receiving unit manage the client's pain effectively. Reviewing the ongoing discharge plan ensures that the client's care continues seamlessly after the transfer. Noting recent physical changes is vital for the receiving unit to monitor the client's condition accurately. Therefore, all of the above findings are essential for ensuring continuity of care and providing comprehensive information to the receiving unit.
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