ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A nurse is caring for an older adult patient who is disoriented and has a history of falls. What actions should the nurse take?
- A. Place the bed in the lowest position, instruct the patient to remain in bed, ensure the bedside table is within reach.
- B. Instruct the patient to use the call light, apply an ambulation alarm to the patient’s leg, check on the patient hourly.
- C. Assign a sitter to monitor the patient, raise the bed rails, provide the patient with a call button.
- D. Check on the patient every two hours, provide verbal reminders to use the call light, lock the bed wheels.
Correct answer: B
Rationale: In this scenario, the correct actions for the nurse to take involve ensuring patient safety and fall prevention measures. Choice B is the correct answer because instructing the patient to use the call light allows them to signal for help, applying an ambulation alarm helps detect movement, and checking on the patient hourly increases monitoring frequency. These actions are essential for preventing falls in a disoriented patient with a history of falls. Choices A, C, and D are incorrect: A does not provide adequate monitoring or fall prevention measures, C relies solely on assigning a sitter without utilizing technological aids, and D lacks continuous monitoring and specific fall prevention strategies.
2. A client with a history of asthma is being cared for by a nurse. Which of the following should the nurse monitor?
- A. Heart rate
- B. Respiratory status
- C. Blood glucose levels
- D. Liver function
Correct answer: B
Rationale: The correct answer is B: Respiratory status. When caring for a client with asthma, it is essential to monitor their respiratory status to detect any changes in breathing or signs of airway obstruction. Monitoring heart rate (choice A) may be important in some situations but is not the priority when managing asthma. Blood glucose levels (choice C) and liver function (choice D) are not directly related to asthma and would not be the primary focus of monitoring for a client with this condition.
3. 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.
4. A nurse is preparing to administer ampicillin 500 mg in 50 mL of dextrose 5% in water (D5W) to infuse over 15 min. The drop factor of the manual IV tubing is 10 gtt/mL. How many gtt/min should the nurse set the manual IV infusion to deliver?
- A. 30 gtt/min
- B. 32 gtt/min
- C. 33 gtt/min
- D. 35 gtt/min
Correct answer: C
Rationale: Calculation: 10 gtt/mL × 50 mL ÷ 15 min = 33.33, rounded to 33 gtt/min. This ensures proper delivery of the medication over the prescribed time. Choice A is incorrect because it does not factor in the precise calculation based on the given data. Choice B is incorrect as it does not reflect the accurate rate of infusion required. Choice D is incorrect as it does not align with the correct calculation based on the drop factor and infusion parameters provided in the question.
5. A public health nurse is developing a list of interventions to address the 3 core functions of public health. What interventions should the nurse include as a part of the assurance function?
- A. Collect data on health trends in the community.
- B. Organize an immunization clinic for at-risk members of the community.
- C. Develop policies to address health disparities.
- D. Conduct research on communicable diseases in the area.
Correct answer: B
Rationale: The correct answer is B: 'Organize an immunization clinic for at-risk members of the community.' The assurance function of public health involves ensuring that essential public health services, like immunizations, are provided to meet public health goals. Choice A, collecting data on health trends, is more aligned with the assessment function of public health. Choice C, developing policies to address health disparities, pertains to the policy development function. Choice D, conducting research on communicable diseases, is related to the research function rather than the assurance function.
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