ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is obtaining the medical history of a client who has a new prescription for isosorbide mononitrate. Which of the following should the nurse identify as a contraindication to this medication?
- A. Glaucoma
- B. Hypertension
- C. Polycythemia
- D. Migraine headaches
Correct answer: A
Rationale: Isosorbide mononitrate is contraindicated in clients with glaucoma due to its potential to increase intraocular pressure, which can exacerbate the condition. Hypertension, polycythemia, and migraine headaches are not contraindications for isosorbide mononitrate. In fact, isosorbide mononitrate is commonly used in the management of hypertension and certain types of angina.
2. A nurse is planning care for a client who has a chest tube. Which of the following actions should the nurse take to ensure proper functioning of the chest tube?
- A. Clamp the chest tube intermittently.
- B. Keep the drainage system below chest level.
- C. Empty the drainage chamber every 4 hours.
- D. Apply sterile gauze around the insertion site daily.
Correct answer: B
Rationale: To ensure proper functioning of a chest tube, the nurse should keep the drainage system below chest level. This position allows for proper drainage by gravity and prevents backflow into the pleural space. Clamping the chest tube intermittently can lead to a buildup of pressure and should be avoided. Emptying the drainage chamber every 4 hours is important but not directly related to maintaining the chest tube's function. Applying sterile gauze around the insertion site daily is essential for infection prevention but does not specifically ensure the proper functioning of the chest tube.
3. A client expresses anxiety about an upcoming surgery. What should the nurse do?
- A. Reassure the client that everything will be fine
- B. Ask the client to describe feelings
- C. Tell the client to stay positive
- D. Provide information about the surgery
Correct answer: B
Rationale: Asking the client to describe their feelings is the most appropriate action for the nurse to take. This allows the nurse to understand the specific concerns and anxieties the client is experiencing. Choice A may invalidate the client's feelings and not address the root cause of anxiety. Choice C may come across as dismissive and oversimplified. While providing information about the surgery (Choice D) is important, addressing the client's emotional state is the initial priority in this situation.
4. A nurse is caring for a client prescribed prednisone. Which of the following should the nurse monitor?
- A. Blood glucose levels
- B. Serum potassium levels
- C. Liver function tests
- D. Heart rate
Correct answer: A
Rationale: Corrected Rationale: Prednisone is known to cause hyperglycemia by increasing blood glucose levels. Monitoring blood glucose levels is crucial to detect and manage any potential hyperglycemic effects of prednisone. While prednisone can also affect serum potassium levels and liver function, the priority monitoring parameter in this case is blood glucose levels. Monitoring heart rate is not directly associated with prednisone administration, making it a less relevant parameter to monitor in this scenario.
5. A nurse is planning a staff education session regarding biological weapons of mass destruction. What should the nurse include in the session?
- A. Rabies, cholera, meningitis
- B. Smallpox, anthrax, botulism
- C. Ebola, hepatitis B, tetanus
- D. Tuberculosis, influenza, measles
Correct answer: B
Rationale: The correct answer is B: Smallpox, anthrax, botulism. These are known biological weapons that can be used in mass casualty situations. Rabies, cholera, and meningitis (Choice A) are not typically used as biological weapons. Ebola, hepatitis B, and tetanus (Choice C) are serious diseases but are not commonly associated with biological warfare. Tuberculosis, influenza, and measles (Choice D) are infectious diseases but are not typically used as biological weapons of mass destruction.
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