ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?
- A. Feeling flushed and warm
- B. Abdominal fullness
- C. Swollen lips
- D. Metallic taste in the mouth
Correct answer: C
Rationale: Swollen lips indicate a potential allergic reaction or anaphylaxis to the contrast dye used during the procedure, which requires immediate medical intervention. Abdominal fullness and metallic taste are common side effects of IV urography and can be managed without urgent intervention. Feeling flushed and warm may also be a common reaction during the procedure and does not indicate a life-threatening situation like an allergic reaction.
2. A nurse is teaching a client with newly diagnosed hypertension about lifestyle changes. Which of the following recommendations should the nurse make?
- A. Limit sodium intake to 3,000 mg per day.
- B. Exercise for at least 30 minutes most days of the week.
- C. Drink no more than two alcoholic drinks per day.
- D. Increase fluid intake to at least 3 liters per day.
Correct answer: B
Rationale: The correct answer is B: 'Exercise for at least 30 minutes most days of the week.' Regular exercise, especially aerobic activity, is known to help lower blood pressure and should be included in lifestyle changes for managing hypertension. Choice A is incorrect because the recommended sodium intake for individuals with hypertension is usually lower than 3,000 mg per day. Choice C is incorrect as it is advisable to limit alcohol intake to one drink per day for women and two drinks per day for men. Choice D is incorrect because increasing fluid intake to 3 liters per day may not be necessary and could be harmful in some cases, depending on the individual's health status.
3. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?
- A. Response to pain medication
- B. Review of ongoing discharge plan
- C. Recent physical changes
- D. All of the above
Correct answer: D
Rationale: When preparing a client for transfer to another unit, the nurse should include all the findings mentioned in the choices in the transfer report. It is crucial to document the client's response to pain medication as it helps the receiving unit manage the client's pain effectively. Reviewing the ongoing discharge plan ensures that the client's care continues seamlessly after the transfer. Noting recent physical changes is vital for the receiving unit to monitor the client's condition accurately. Therefore, all of the above findings are essential for ensuring continuity of care and providing comprehensive information to the receiving unit.
4. A nurse is teaching a client about the use of gabapentin. Which of the following should be included?
- A. It can cause drowsiness
- B. It has no side effects
- C. It is a pain reliever
- D. It can be taken with food
Correct answer: A
Rationale: The correct answer is A: 'It can cause drowsiness.' Gabapentin is known to cause drowsiness, and clients should be warned about this side effect. Choice B is incorrect because gabapentin, like any medication, can have side effects. Choice C is incorrect because although gabapentin is used for pain management, it is not classified as a pain reliever. Choice D is incorrect because gabapentin should be taken as prescribed by the healthcare provider, and specific instructions regarding food intake should be provided based on individual needs.
5. A nurse is preparing to administer a dose of warfarin. Which of the following should the nurse do?
- A. Check INR levels
- B. Administer it with food
- C. Monitor blood glucose
- D. Assess liver function
Correct answer: A
Rationale: The correct answer is to check INR levels. Before administering warfarin, it is crucial to check the INR levels to ensure they are within the therapeutic range. This helps to prevent complications such as bleeding or clotting. Choice B, administering it with food, is incorrect as warfarin should typically be taken on an empty stomach. Choice C, monitoring blood glucose, is unrelated to the administration of warfarin. Choice D, assessing liver function, is important but not the immediate action required before administering warfarin.
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