ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. 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.
2. A client is postpartum and has idiopathic thrombocytopenic purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count
- B. Increased erythrocyte sedimentation rate (ESR)
- C. Decreased megakaryocytes
- D. Increased WBC
Correct answer: A
Rationale: Idiopathic thrombocytopenic purpura (ITP) is characterized by an autoimmune response that leads to a decreased platelet count. This condition increases the risk of bleeding due to the low platelet levels. Monitoring the platelet count is crucial in managing ITP, as it helps determine the risk of bleeding and guides treatment decisions. Therefore, the correct finding to expect in a client with ITP is a decreased platelet count. Choice B, an increased erythrocyte sedimentation rate (ESR), is not typically associated with ITP. Choice C, decreased megakaryocytes, may be seen in conditions like aplastic anemia but are not a typical finding in ITP. Choice D, an increased white blood cell count (WBC), is not a characteristic feature of ITP.
3. What is the primary benefit of cognitive-behavioral therapy (CBT) for patients with anxiety disorders?
- A. It focuses on the long-term use of medications.
- B. It helps patients understand and change their thought patterns.
- C. It primarily addresses childhood traumas.
- D. It encourages patients to avoid anxiety-provoking situations.
Correct answer: B
Rationale: The primary benefit of cognitive-behavioral therapy (CBT) for patients with anxiety disorders is that it helps individuals understand and change their thought patterns. By doing so, patients can effectively reduce their anxiety levels by altering their responses to anxious thoughts and situations, leading to improved coping mechanisms and overall well-being. Choice A is incorrect because CBT does not focus on the long-term use of medications but rather on changing cognitive patterns. Choice C is incorrect because while CBT may address past experiences, its primary focus is on current thoughts and behaviors. Choice D is incorrect as CBT aims to help patients confront and manage anxiety-provoking situations rather than avoid them.
4. A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention?
- A. Two to three soft bowel movements daily
- B. Significant increase in appetite and food intake
- C. Absence of nausea and vomiting
- D. Absence of blood or mucus in stool
Correct answer: A
Rationale: Lactulose is used in hepatic encephalopathy to reduce blood ammonia levels by promoting bowel movements. The desired outcome of lactulose therapy is typically two to three soft bowel movements daily, which helps in eliminating excess ammonia from the body, thus improving the client's condition.
5. What is the first step in preparing a blood transfusion?
- A. Administer the blood via IV push
- B. Verify the client's blood type before starting the transfusion
- C. Warm the blood to body temperature before administration
- D. Administer diuretics to prevent fluid overload
Correct answer: B
Rationale: The correct first step in preparing a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to ensure compatibility and prevent adverse reactions. Administering the blood via IV push (Choice A) is incorrect as it skips the essential step of verifying the blood type. Warming the blood to body temperature (Choice C) is important but comes after verifying the blood type. Administering diuretics (Choice D) is not part of the preparation process for a blood transfusion.
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