ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A nurse is caring for a client with a stage 2 pressure ulcer. Define the characteristics of the ulcer.
- A. Intact skin with nonblanchable redness (Stage 1)
- B. Full-thickness tissue loss with subQ damage (Stage 3)
- C. Partial-thickness skin loss involving the epidermis and dermis
- D. Full-thickness tissue loss with damage to muscle or bone (Stage 4)
Correct answer: C
Rationale: The correct answer is C. Stage 2 ulcers involve partial-thickness skin loss with visible and superficial damage, which may appear as an abrasion, blister, or shallow crater. Choice A describes a Stage 1 pressure ulcer characterized by intact skin with nonblanchable redness. Choice B describes a Stage 3 pressure ulcer with full-thickness tissue loss and damage to the subcutaneous tissue. Choice D is indicative of a Stage 4 pressure ulcer, involving full-thickness tissue loss with damage extending to muscle or bone.
2. Who were the first public health nurses who provided care for the sick and the poor?
- A. The Presbyterian Church
- B. Salerno
- C. Jewish scholars
- D. Convent deaconesses
Correct answer: D
Rationale: The correct answer is D, Convent deaconesses. Deaconesses from local convents were the first public health nurses who provided care for the sick and the poor. They exemplified care guided by the Christian belief in compassion and helping others. The other choices (A, B, C) are incorrect because the Presbyterian Church, Salerno, and Jewish scholars were not specifically mentioned as the pioneers of public health nursing. The extract highlights the significant role of convent deaconesses in laying the foundation for modern public health nursing.
3. A patient with cirrhosis of the liver and ascites is scheduled for a paracentesis. What should the nurse do to prepare the patient for the procedure?
- A. Have the patient void immediately before the procedure.
- B. Position the patient upright or semi-Fowler's in bed.
- C. Administer a full liquid diet.
- D. Encourage the patient to ambulate for 30 minutes.
Correct answer: A
Rationale: The correct preparation for a paracentesis in a patient with cirrhosis and ascites includes having the patient void immediately before the procedure. This is important to reduce the risk of bladder puncture during the paracentesis. Positioning for a paracentesis is typically upright or semi-Fowler's, not flat in bed. Administering a full liquid diet or encouraging ambulation for 30 minutes are not directly related to preparing a patient for a paracentesis procedure.
4. The nurse is performing triage on a group of clients in the emergency department. Which of the following clients should the nurse see first?
- A. A 12-year-old oozing blood from a laceration on the left thumb due to a cut from a rusty metal can
- B. A 19-year-old with a fever of 103.8°F who is able to identify her sister but not the place and time
- C. A 49-year-old with a compound fracture of the right leg who is complaining of severe pain
- D. A 65-year-old with a flushed face, dry mucous membranes, and a blood sugar of 470 mg/dL
Correct answer: B
Rationale: The correct answer is B. A 19-year-old with a fever of 103.8°F who is confused and unable to orient to place and time likely has a severe infection or a serious medical condition affecting the central nervous system. This client needs immediate attention as altered mental status combined with a high fever can indicate a life-threatening situation. Choices A, C, and D present important conditions that require medical care, but they are not as urgent as the 19-year-old with a high fever and confusion. The 12-year-old with a laceration may require treatment for bleeding and a tetanus shot, the 49-year-old with a compound fracture needs urgent orthopedic intervention, and the 65-year-old with a high blood sugar is concerning for hyperglycemia but can wait momentarily compared to the client with a fever and altered mental status.
5. A healthcare professional is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following instructions should the healthcare professional include?
- A. Avoid drinking grapefruit juice.
- B. Take aspirin for pain relief.
- C. Consume a consistent amount of green leafy vegetables.
- D. Use an electric razor when shaving.
Correct answer: C
Rationale: Consuming a consistent amount of green leafy vegetables is important for clients taking warfarin as these foods contain vitamin K, which can affect the medication's effectiveness. Maintaining a consistent intake helps stabilize the International Normalized Ratio (INR) levels, which is crucial for monitoring the blood's ability to clot properly while on warfarin therapy. Choices A, B, and D are incorrect. Avoiding grapefruit juice is generally recommended with certain medications due to its interaction with liver enzymes, which is not directly related to warfarin. Taking aspirin along with warfarin can increase the risk of bleeding. Using an electric razor when shaving is a safety precaution for those at risk of bleeding, but it is not directly related to the medication warfarin.
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