ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is caring for a client with deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Position the client with the affected leg below the heart
- B. Massage the affected extremity every 4 hours
- C. Apply cold compresses to the affected extremity
- D. Elevate the affected leg while in bed
Correct answer: D
Rationale: The correct answer is to elevate the affected leg while in bed. Elevating the leg helps reduce swelling and promotes venous return, aiding in the management of DVT. Positioning the affected leg below the heart can worsen the condition by increasing the risk of clot dislodgment. Massaging the affected extremity can also dislodge the clot and should be avoided. Cold compresses are not recommended as they can cause vasoconstriction, potentially worsening the condition.
2. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following statements should the nurse include in the teaching?
- A. You can still eat sugar, but you must count it in your carbohydrate count for the day.
- B. You need to avoid all forms of sugar to keep your blood glucose levels under control.
- C. You can eat unlimited amounts of proteins and fats since they do not affect blood glucose levels.
- D. You will need to take an oral hypoglycemic agent every day to manage your blood glucose levels.
Correct answer: A
Rationale: The correct statement to include in teaching a client with type 1 diabetes mellitus is that they can still eat sugar, but they must count it in their carbohydrate intake for the day. This is important because clients with type 1 diabetes need to manage their blood glucose levels by calculating their carbohydrate intake, including sugars. Choice B is incorrect because total avoidance of sugar is not necessary, but monitoring and including it in the carbohydrate count is essential. Choice C is incorrect as proteins and fats can also affect blood glucose levels and should be consumed in moderation. Choice D is incorrect since oral hypoglycemic agents are not used in type 1 diabetes mellitus, as insulin replacement therapy is the mainstay of treatment.
3. The client has acute kidney injury (AKI). Which assessment finding requires immediate intervention?
- A. Urine output of 50 ml in the last hour.
- B. Serum potassium of 6.2 mEq/L.
- C. Blood pressure of 150/90 mm Hg.
- D. Serum creatinine of 2.5 mg/dL.
Correct answer: B
Rationale: An elevated serum potassium level of 6.2 mEq/L in a client with AKI can lead to life-threatening cardiac arrhythmias, necessitating immediate intervention. Hyperkalemia is a serious complication in AKI as impaired kidney function can result in the accumulation of potassium in the blood, posing a risk of cardiac arrest. Prompt treatment to lower potassium levels is crucial to prevent cardiac complications in this situation.
4. The charge nurse observes that a client with a nasogastric tube on low intermittent suction is drinking a glass of water immediately after the unlicensed assistive personnel (UAP) left the room. What action should the nurse take?
- A. Remove the glass of water and speak to the UAP.
- B. Discuss the incident with the UAP at the end of the day.
- C. Write an incident report and notify the healthcare provider.
- D. Remind the client of the potential for electrolyte imbalance.
Correct answer: A
Rationale: The correct action for the charge nurse to take is to remove the glass of water and speak to the UAP. This ensures immediate correction and education to prevent further issues with the nasogastric tube. Addressing the situation promptly can prevent harm to the client and reinforces the importance of following proper protocols.
5. Which of the following is the most effective method for preventing the spread of infectious diseases?
- A. Antibiotic treatment
- B. Quarantine of infected individuals
- C. Vaccination
- D. Nutritional supplementation
Correct answer: C
Rationale: Vaccination is the most effective method for preventing the spread of infectious diseases as it helps in developing immunity against specific pathogens, reducing the likelihood of infection and transmission within a population. Antibiotics are used to treat infections, not prevent their spread. Quarantine limits the contact of infected individuals but does not provide long-term prevention. Nutritional supplementation can support overall health but is not a primary method for preventing infectious diseases.
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