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 nurse is assessing a client for signs of heart failure. Which of the following findings should the nurse monitor?
- A. Decreased heart rate
- B. Peripheral edema
- C. Increased energy levels
- D. Hyperglycemia
Correct answer: B
Rationale: The correct answer is B: Peripheral edema. Peripheral edema, the accumulation of fluid causing swelling in the extremities, is a classic sign of heart failure due to fluid overload. This occurs because the heart's reduced pumping efficiency leads to fluid backup in the circulatory system. Choices A, C, and D are incorrect. Decreased heart rate is not typically associated with heart failure; instead, tachycardia or an increased heart rate may be observed. Increased energy levels are not an expected finding in heart failure, as this condition often causes fatigue and weakness. Hyperglycemia is not a direct sign of heart failure; however, it can be present in individuals with uncontrolled diabetes or as a result of certain treatments, but it is not a specific indicator of heart failure.
3. A nurse is providing dietary teaching to a client who is at risk for cardiovascular disease. Which of the following foods should the nurse recommend?
- A. Fried chicken
- B. Oatmeal
- C. Bacon
- D. Whole milk
Correct answer: B
Rationale: Oatmeal is high in fiber, which helps lower cholesterol levels, making it a heart-healthy food option for clients at risk for cardiovascular disease. Fried chicken, bacon, and whole milk are high in saturated fats and cholesterol, which can increase the risk of heart disease and should be limited in the diet of individuals at risk for cardiovascular issues.
4. A nurse is preparing to administer a dose of losartan. Which of the following should the nurse assess first?
- A. Blood pressure
- B. Heart rate
- C. Serum potassium
- D. Liver function
Correct answer: A
Rationale: The correct answer is to assess blood pressure first. Losartan is an angiotensin receptor blocker used to lower blood pressure. Assessing the patient's blood pressure before administering losartan is crucial to ensure it is not already too low, which could lead to hypotension. Assessing heart rate (choice B) is important but not the priority when administering losartan. Serum potassium levels (choice C) and liver function (choice D) are also important assessments, but they are not the primary concern before administering losartan.
5. A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching?
- A. Hydrogen peroxide
- B. Chlorhexidine
- C. Isopropyl alcohol
- D. Chlorine bleach
Correct answer: D
Rationale: Chlorine bleach is the recommended agent for cleaning blood spills due to its effectiveness in killing bloodborne pathogens like HIV and hepatitis B. Hydrogen peroxide, Chlorhexidine, and Isopropyl alcohol are not as effective as chlorine bleach in disinfecting surfaces contaminated with blood and eliminating bloodborne pathogens, making them incorrect choices.
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