ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a toddler with respiratory syncytial virus (RSV). Which action should the nurse take?
- A. Use a designated stethoscope for the toddler
- B. Wear an N95 respirator mask when caring for the toddler
- C. Place the toddler in a negative pressure room
- D. Remove the disposable gown before leaving the toddler's room
Correct answer: A
Rationale: Using a designated stethoscope for the toddler is crucial to reduce the risk of spreading RSV to other patients. Choice B is incorrect because N95 respirator masks are not specifically indicated for RSV. Choice C is unnecessary as RSV does not require isolation in a negative pressure room. Choice D is incorrect because the gown should be removed after leaving the room to prevent transmission of pathogens to other areas.
2. A nurse is providing discharge teaching to a client with heart failure and a prescription for furosemide 20 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?
- A. Monitor for increased blood pressure
- B. Increase intake of high-potassium foods
- C. Expect an increase in swelling in the hands and feet
- D. Take the second dose at bedtime
Correct answer: B
Rationale: The correct answer is B: "Increase intake of high-potassium foods." Furosemide is a loop diuretic that can lead to hypokalemia, a condition characterized by low potassium levels. To prevent this adverse effect, the client should increase their intake of high-potassium foods. Choice A is incorrect because furosemide typically leads to decreased blood pressure, not increased. Choice C is incorrect because furosemide is used to reduce swelling, not increase it. Choice D is incorrect because the second dose of furosemide should be taken in the morning to prevent nocturia.
3. A postpartum complication a client is at risk for is deep-vein thrombosis. Which of the following factors is strongly associated with this postpartum complication?
- A. Cesarean birth
- B. Vaginal birth
- C. Anemia
- D. Multiparity
Correct answer: A
Rationale: The correct answer is A: Cesarean birth. Cesarean birth doubles the risk for deep-vein thrombosis (DVT) due to immobility and vascular changes associated with surgery. Other risk factors for DVT include smoking, obesity, and a history of thromboembolism. Vaginal birth, anemia, and multiparity are not strongly associated with an increased risk of deep-vein thrombosis postpartum. It is important to educate clients undergoing cesarean birth about the increased risk of DVT and measures to prevent it, such as early ambulation and the use of compression stockings.
4. A client who is 38 weeks pregnant with herpes simplex virus is admitted to labor and delivery. What question should the nurse ask?
- A. Do you have any active lesions?
- B. Have your membranes ruptured?
- C. How far apart are your contractions?
- D. Are you positive for beta strep?
Correct answer: A
Rationale: The correct question the nurse should ask the client who is 38 weeks pregnant with herpes simplex virus is 'Do you have any active lesions?' This is crucial because active herpes lesions may necessitate a cesarean delivery to prevent neonatal infection. Choice B, 'Have your membranes ruptured?' is related to assessing for the rupture of membranes, not specific to the client's herpes infection. Choice C, 'How far apart are your contractions?' is related to monitoring labor progress. Choice D, 'Are you positive for beta strep?' is related to group B streptococcus screening, which is important but not the priority in this scenario.
5. A client with heart failure and a new prescription for furosemide is receiving teaching from a nurse. Which of the following instructions should the nurse include?
- A. Avoid foods high in magnesium
- B. Take furosemide with food
- C. Eat foods that are rich in potassium
- D. Expect a decrease in blood pressure
Correct answer: C
Rationale: The correct instruction the nurse should include is to advise the client to eat foods that are rich in potassium. Furosemide is a loop diuretic that can cause the loss of potassium, leading to hypokalemia. Eating foods high in potassium can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide does not directly interact with magnesium. Choice B is incorrect because furosemide is usually taken in the morning to prevent nighttime diuresis. Choice D is incorrect because furosemide is a diuretic that typically leads to a decrease in blood pressure rather than an increase.
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