ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is caring for a toddler diagnosed with respiratory syncytial virus (RSV). Which of the following actions should the nurse take?
- A. Use a designated stethoscope when caring for the toddler
- B. Wear an N95 respirator mask
- C. Remove the disposable gown after leaving the toddler’s room
- D. Place the toddler in a room with negative air pressure
Correct answer: A
Rationale: Using a designated stethoscope is the correct action when caring for a toddler diagnosed with RSV. This measure helps prevent the spread of infection to other clients by reducing the risk of contamination. Wearing an N95 respirator mask is not necessary for routine care of a toddler with RSV unless performing aerosol-generating procedures. Removing the disposable gown after leaving the toddler's room is important for infection control but not specific to RSV care. Placing the toddler in a room with negative air pressure is not a standard practice for managing RSV in toddlers.
2. A client who is having suicidal thoughts tells the nurse, “It just doesn’t seem worth it anymore. Why not end my misery?” Which of the following responses by the nurse is appropriate?
- A. Why do you think your life is not worth it anymore?
- B. Do you have a plan to end your life?
- C. I need to know what you mean by misery
- D. You can trust me and tell me what you’re thinking
Correct answer: B
Rationale: The appropriate response by the nurse is to ask about the client's plan to end their life. This question helps to assess the severity of the client's suicidal ideation and the immediacy of the risk, allowing the nurse to determine the appropriate level of intervention. Choices A, C, and D do not directly address the immediate risk assessment needed in this situation.
3. A healthcare provider is caring for a client receiving total parenteral nutrition (TPN). Which of the following should the healthcare provider monitor?
- A. Serum glucose levels
- B. Serum potassium levels
- C. Blood pressure
- D. Both A and B
Correct answer: D
Rationale: When caring for a client receiving total parenteral nutrition (TPN), monitoring serum glucose levels is essential due to the impact TPN can have on glucose metabolism. Additionally, electrolytes like potassium should be monitored as they can be affected by TPN administration. Blood pressure monitoring is not directly related to TPN administration, making choices A and B the correct options to monitor in this scenario.
4. A nurse is caring for a client with a prescription for ferrous sulfate. What instruction should the nurse provide?
- A. Avoid strawberries and citrus fruits
- B. Take with fluids other than coffee or tea
- C. Take on a full stomach
- D. Double the dose if you miss a dose
Correct answer: B
Rationale: The correct instruction for a client prescribed ferrous sulfate is to take it with fluids other than coffee or tea. Coffee and tea can hinder iron absorption, so it's important to take the medication with other types of fluids. Choice A is incorrect because strawberries and citrus fruits are sources of vitamin C, which actually enhance iron absorption. Choice C is incorrect because ferrous sulfate is usually recommended to be taken on an empty stomach for better absorption. Choice D is incorrect as doubling the dose of ferrous sulfate can lead to an overdose and severe side effects.
5. A nurse is caring for a client with a history of heroin use who is intoxicated. Which finding should the nurse expect?
- A. Constricted pupils
- B. Dilated pupils
- C. Increased reflexes
- D. Elevated blood pressure
Correct answer: A
Rationale: The correct answer is A: Constricted pupils. Constricted pupils are a classic sign of opioid intoxication, including heroin. Opioids like heroin cause the pupils to constrict due to their effect on the autonomic nervous system. Dilated pupils, increased reflexes, and elevated blood pressure are not typically associated with opioid intoxication but may be seen with other substances or conditions.
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