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 nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?
- A. Heart rate 120/min
- B. Urine output 30 mL/hour
- C. Blood pressure 110/70 mmHg
- D. Skin turgor is normal
Correct answer: A
Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement. Elevated heart rate is a sensitive indicator of dehydration as the body attempts to maintain cardiac output. Urine output of 30 mL/hour is within the normal range (30 mL/hour is the minimum acceptable urine output for an adult). Blood pressure of 110/70 mmHg is within the normal range. Normal skin turgor is a positive sign indicating adequate hydration.
3. A client with a new diagnosis of hypertension is being taught about lifestyle modifications by a nurse. What dietary change should the nurse recommend?
- A. Increase sodium intake
- B. Limit alcohol consumption
- C. Eat a high-protein diet
- D. Follow a high-fat diet
Correct answer: B
Rationale: The correct answer is B: Limit alcohol consumption. When managing hypertension, it is crucial to reduce alcohol intake as it can raise blood pressure. High alcohol consumption can also interfere with the effectiveness of antihypertensive medications. Choices A, C, and D are incorrect. Increasing sodium intake (Choice A) is not recommended for hypertension as it can lead to fluid retention and elevated blood pressure. Eating a high-protein diet (Choice C) or following a high-fat diet (Choice D) are also not ideal for managing hypertension, as they can have negative impacts on cardiovascular health.
4. A client prescribed allopurinol for gout is being taught by a nurse. Which of the following should be included in the teaching?
- A. Take the medication with meals.
- B. Drink at least 2 liters of water per day.
- C. Avoid foods high in purines.
- D. Increase your dietary intake of calcium.
Correct answer: B
Rationale: The correct answer is B: 'Drink at least 2 liters of water per day.' Clients taking allopurinol should be instructed to drink plenty of water to prevent kidney stones, a potential side effect of the medication. Option A is incorrect because allopurinol is usually taken without regard to meals. Option C is not directly related to the teaching about allopurinol, as it pertains more to dietary management of gout. Option D is also unrelated to allopurinol use for gout.
5. A nurse is caring for a client newly prescribed doxazosin mesylate. Which of the following instructions should the nurse include in client education regarding taking the first dose of this medication?
- A. Change positions slowly and lie down if dizziness occurs
- B. There is no need to avoid normal activities
- C. Avoid dairy products while taking this medication
- D. Do not eat green leafy vegetables
Correct answer: A
Rationale: The correct answer is A. Doxazosin can cause first-dose orthostatic hypotension, which may lead to dizziness or fainting when the client stands up too quickly. The nurse should advise the client to change positions slowly and lie down if dizziness occurs to prevent falls and other injuries. Choice B is incorrect because while the client can continue normal activities, caution should be taken with position changes. Choice C is incorrect as doxazosin does not interact with dairy products. Choice D is incorrect as there is no need to avoid green leafy vegetables specifically while taking doxazosin.
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