ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is educating a patient about their new prescription for a statin medication. What should the nurse advise the patient to avoid while taking this medication?
- A. Drinking grapefruit juice
- B. Consuming high-protein meals
- C. Exercising regularly
- D. Taking the medication in the morning
Correct answer: A
Rationale: The correct answer is A: Drinking grapefruit juice. Grapefruit juice can increase the risk of statin toxicity by interfering with the enzyme that metabolizes statin medications, leading to higher drug levels in the body. This interaction can potentially cause adverse effects. Therefore, patients should be advised to avoid consuming grapefruit juice while taking statins. Choices B, C, and D are incorrect. Consuming high-protein meals, exercising regularly, and taking the medication in the morning are not contraindicated while on statin therapy. In fact, following a healthy diet, engaging in physical activity, and taking the medication at a consistent time each day can be beneficial for patients prescribed statins.
2. A client is prescribed spironolactone. Which of the following dietary instructions should the nurse include?
- A. Increase potassium-rich foods
- B. Limit sodium intake
- C. Avoid potassium supplements
- D. Increase protein intake
Correct answer: C
Rationale: The correct answer is to advise the client to avoid potassium supplements. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Adding potassium supplements on top of this medication can lead to hyperkalemia, an elevated level of potassium in the blood, which can be dangerous. Choices A, B, and D are incorrect because increasing potassium-rich foods, limiting sodium intake, and increasing protein intake are not specifically related to the dietary considerations when taking spironolactone.
3. A nurse receives a report on four clients. Which client should the nurse assess first?
- A. A client scheduled for chemotherapy with a hemoglobin of 9 g/dL
- B. A client 24 hours post-TURP with small blood clots in the catheter
- C. A client receiving a blood transfusion who reports low back pain
- D. A client with a new colostomy and a reddish-pink stoma
Correct answer: C
Rationale: The correct answer is C. Low back pain during a blood transfusion is a classic sign of a transfusion reaction, specifically a transfusion-associated circulatory overload (TACO) or hemolytic reaction, both of which require immediate attention to prevent serious complications. Assessing this client first is crucial to ensure prompt intervention. Choices A, B, and D do not indicate immediate life-threatening complications and can be addressed after the client experiencing low back pain during a blood transfusion is stabilized.
4. 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.
5. A healthcare provider is caring for a patient and realizes they administered the wrong medication. What action should the healthcare provider take first?
- A. Notify the provider.
- B. Report the incident to the risk manager.
- C. Check the condition of the patient.
- D. Complete an incident report.
Correct answer: C
Rationale: The healthcare provider should first assess the patient to determine if any harm has occurred as a result of the medication error. Checking the patient's condition takes precedence as it allows for immediate intervention if necessary. Notifying the provider (choice A) can come later once the patient's condition is assessed. Reporting to the risk manager (choice B) and completing an incident report (choice D) are important steps but should follow the initial assessment of the patient to ensure timely and appropriate actions are taken.
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