ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. 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.
2. A nurse is caring for a client with Alzheimer’s disease. Which action should the nurse include in the plan of care to support the client’s cognitive function?
- A. Place a daily calendar in the kitchen
- B. Replace buttoned clothing with zippered items
- C. Replace the carpet with hardwood floors
- D. Create variation in the daily routine
Correct answer: A
Rationale: Placing a daily calendar in the kitchen is essential to help clients with Alzheimer's stay oriented to time and maintain cognitive function. It supports their ability to recall the day, date, and upcoming events, promoting a sense of control over their environment. Choices B, C, and D do not directly target cognitive function support in clients with Alzheimer's disease. While replacing buttoned clothing with zippered items may aid in dressing independently, changing the flooring or introducing variation in the daily routine does not specifically address cognitive function support.
3. A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority to report to the provider?
- A. Constipation
- B. Blurred vision
- C. Fever
- D. Dry mouth
Correct answer: C
Rationale: The correct answer is C: Fever. Clozapine can cause agranulocytosis, a serious condition that leads to infections. Fever may indicate an underlying infection, a potentially life-threatening complication, and must be reported immediately to the provider for further evaluation and management. Choice A (Constipation) is a common side effect of clozapine but is not as urgent as fever. Blurred vision (Choice B) and dry mouth (Choice D) are side effects of clozapine but are not indicative of a life-threatening condition like agranulocytosis.
4. A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?
- A. Redness at the site
- B. Warmth around the site
- C. Edema
- D. Pain at the site
Correct answer: C
Rationale: Edema at the IV site indicates that IV solution has leaked into the extravascular tissue, which is a sign of infiltration. Redness, warmth, and pain at the site are more indicative of phlebitis, not infiltration. Phlebitis is characterized by redness, warmth, and pain along the vein where the IV is placed, while infiltration involves the leaking of IV fluids into the surrounding tissue.
5. A nurse is teaching a client about nonpharmacological pain management techniques. Which statement about hypnosis is appropriate?
- A. Hypnosis promotes increased control of pain perception during labor
- B. Hypnosis uses therapeutic touch to reduce anxiety
- C. Hypnosis focuses on biofeedback as a relaxation technique
- D. Hypnosis provides instruction to minimize pain
Correct answer: A
Rationale: The correct answer is A: "Hypnosis promotes increased control of pain perception during labor." Hypnosis can be effectively utilized during labor to help individuals enhance their control over how they perceive pain. Choice B is incorrect because hypnosis does not primarily use therapeutic touch to reduce anxiety. Choice C is incorrect as hypnosis is not primarily focused on biofeedback as a relaxation technique. Choice D is incorrect because hypnosis does not provide direct instructions to minimize pain but rather helps individuals gain control over their pain perception.
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