ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. When caring for a client with a sealed radiation implant, which action should be included in the plan of care?
- A. Remove dirty linens after double bagging them
- B. Wear a dosimeter film badge while in the client’s room
- C. Limit visitors to 1 hour per day
- D. Ensure family members remain at least 3 feet from the client
Correct answer: B
Rationale: The correct answer is to wear a dosimeter film badge while in the client's room. This is crucial for monitoring radiation exposure levels when caring for a client with a sealed radiation implant. Option A is incorrect as removing dirty linens after double bagging them is not directly related to radiation safety. Option C is incorrect as there is no specific guideline to limit visitors to 1 hour per day for clients with sealed radiation implants. Option D is incorrect as the distance of family members from the client is not a primary safety measure when dealing with sealed radiation implants.
2. A client has been taking propranolol. Which of the following findings indicates a need to withhold the medication?
- A. Sodium 130 mEq/L
- B. Blood pressure 156/90 mm Hg
- C. Potassium 5.2 mEq/L
- D. Pulse 54/min
Correct answer: D
Rationale: A pulse of 54/min indicates bradycardia, which is a side effect of propranolol, a beta-blocker. The medication should be withheld if the client's pulse drops below 60/min. The other findings (sodium levels, blood pressure, and potassium levels) are not directly indicative of the need to withhold propranolol.
3. A nurse is caring for a client who has peptic ulcer disease (PUD) and is prescribed sucralfate. Which of the following instructions should the nurse include in the teaching?
- A. Take sucralfate with an antacid.
- B. Take sucralfate 1 hour before meals.
- C. Take sucralfate with food.
- D. Take sucralfate at bedtime only.
Correct answer: B
Rationale: The correct answer is B. Sucralfate should be taken on an empty stomach, 1 hour before meals. This timing allows sucralfate to form a protective barrier over the ulcer, enhancing healing. Choice A is incorrect because sucralfate should not be taken with an antacid. Choice C is incorrect because sucralfate should not be taken with food. Choice D is incorrect because sucralfate should not be taken at bedtime only; it is best absorbed on an empty stomach.
4. A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?
- A. Feeling flushed and warm
- B. Abdominal fullness
- C. Swollen lips
- D. Metallic taste in the mouth
Correct answer: C
Rationale: Swollen lips indicate a potential allergic reaction or anaphylaxis to the contrast dye used during the procedure, which requires immediate medical intervention. Abdominal fullness and metallic taste are common side effects of IV urography and can be managed without urgent intervention. Feeling flushed and warm may also be a common reaction during the procedure and does not indicate a life-threatening situation like an allergic reaction.
5. A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?
- A. I will make sure my medications are enteric-coated.
- B. My stoma will drain liquid continuously.
- C. I will change my pouch system every two weeks.
- D. My stoma size will stay the same after it heals.
Correct answer: B
Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.
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