ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions should the nurse take?
- A. Apply tape to the client’s skin before surgery.
- B. Ensure the surgical suite is well-ventilated.
- C. Wrap monitoring cords with stockinette.
- D. Schedule the surgery at the end of the day.
Correct answer: C
Rationale: The correct action the nurse should take is to wrap monitoring cords with stockinette. This measure ensures that the latex in the cords does not come into contact with the client’s skin, reducing the risk of an allergic reaction. Applying tape to the client’s skin before surgery (Choice A) may expose the client to latex if the tape contains latex. Ensuring the surgical suite is well-ventilated (Choice B) is important for overall safety but does not specifically address the client's latex allergy. Scheduling the surgery at the end of the day (Choice D) is not directly related to preventing latex exposure and allergic reactions.
2. A client presents with symptoms suggestive of rheumatoid arthritis. Which of the following laboratory tests should be ordered to confirm this diagnosis?
- A. Erythrocyte sedimentation rate (ESR)
- B. Rheumatoid factor
- C. Antinuclear antibody
- D. Serum calcium
Correct answer: B
Rationale: Rheumatoid factor is a specific marker for rheumatoid arthritis. It is often elevated in clients with this autoimmune condition, helping to confirm the diagnosis. Erythrocyte sedimentation rate (ESR) and antinuclear antibody tests can be supportive but are not specific for rheumatoid arthritis. Serum calcium levels are not typically used to confirm this diagnosis.
3. A healthcare professional is assessing a client in the PACU. Which of the following findings indicates decreased cardiac output?
- A. Shivering
- B. Oliguria
- C. Bradypnea
- D. Constricted pupils
Correct answer: B
Rationale: Oliguria (low urine output) is a sign of decreased cardiac output because the kidneys are not being adequately perfused, leading to reduced urine production. Shivering (choice A) is a response to hypothermia, not directly related to cardiac output. Bradypnea (choice C) refers to abnormally slow breathing rate and is not a direct indicator of decreased cardiac output. Constricted pupils (choice D) can be caused by medications or sympathetic nervous system stimulation but are not specific to decreased cardiac output.
4. A client is admitted for observation and has full range of motion. Which is the best manner to encourage the client to void?
- A. Urinal
- B. Bedpan
- C. Bedside Commode
- D. Client Bathroom
Correct answer: D
Rationale: The correct answer is D: Client Bathroom. Encouraging the client to use the bathroom is the best way to promote independence and privacy, maintaining normal function. In this case, since the client has full range of motion, using the client bathroom would be the most appropriate choice. Options A, B, and C (Urinal, Bedpan, Bedside Commode) are not the best choices as they may restrict the client's independence and privacy, which can impact their psychological well-being and normal voiding function.
5. A nurse is caring for a client who has a prescription for enalapril. The nurse should monitor the client for which of the following adverse effects of this medication?
- A. Bradycardia
- B. Hyperkalemia
- C. Hyperglycemia
- D. Tinnitus
Correct answer: B
Rationale: The correct answer is B: Hyperkalemia. Enalapril, an ACE inhibitor, can lead to hyperkalemia by reducing aldosterone levels, which results in potassium retention. Bradycardia (Choice A) is not a common adverse effect of enalapril. Hyperglycemia (Choice C) and tinnitus (Choice D) are also not typically associated with enalapril use.
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