ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for one week. Which of the following should the nurse include in the plan of care?
- A. Remove dirty linens from the room after double-bagging them
- B. Wear a dosimeter film badge while in the client’s room
- C. Limit each visitor to one hour per day
- D. Ensure family members remain at least 3 feet from the client
Correct answer: B
Rationale: The correct answer is to wear a dosimeter film badge while in the client's room. Wearing a dosimeter helps monitor the cumulative radiation exposure of healthcare workers, ensuring their safety during care. Removing dirty linens, limiting visitor time, and maintaining a distance from the client are not directly related to radiation safety measures and are not necessary in this scenario.
2. A nurse is caring for a client who has been taking haloperidol for several years. Which of the following assessment findings should the nurse recognize as a long-term side effect of this medication?
- A. Lip-smacking
- B. Agranulocytosis
- C. Clang association
- D. Alopecia
Correct answer: A
Rationale: Lip-smacking is a symptom of tardive dyskinesia, a long-term side effect of antipsychotic medications like haloperidol, characterized by involuntary movements of the face and jaw. Agranulocytosis (Choice B) is a rare but serious side effect of some medications, characterized by a dangerously low white blood cell count. Clang association (Choice C) is a thought disorder characterized by the association of words based on sound rather than meaning. Alopecia (Choice D) refers to hair loss, which is not a known long-term side effect of haloperidol.
3. A healthcare provider is providing education on the use of atorvastatin. Which of the following should be included?
- A. Monitor for liver function
- B. It can cause muscle pain
- C. It is safe to take during pregnancy
- D. Both A and B
Correct answer: D
Rationale: Atorvastatin requires monitoring for liver function due to its potential to cause liver abnormalities. It can also lead to muscle pain or weakness, a condition known as myopathy. Choice C is incorrect as atorvastatin is contraindicated during pregnancy due to potential harm to the fetus, making choices A and B the correct options to include in patient education.
4. A healthcare professional is preparing to administer a dose of nitroglycerin. Which of the following should be assessed first?
- A. Blood pressure
- B. Heart rate
- C. Pain level
- D. Respiratory rate
Correct answer: A
Rationale: The correct answer is to assess blood pressure first before administering nitroglycerin. Nitroglycerin is a vasodilator that can cause a sudden drop in blood pressure, leading to adverse effects such as dizziness or fainting. Assessing blood pressure before administration helps determine if the patient's blood pressure is within the acceptable range for nitroglycerin administration. Heart rate, pain level, and respiratory rate are also important assessments, but blood pressure should take precedence due to the vasodilating effects of nitroglycerin.
5. A client has a stool culture positive for C. difficile. What action should the nurse take?
- A. Place the client in a negative pressure room
- B. Use alcohol-based hand rub after providing care
- C. Wear a face shield before entering the room
- D. Place the client in a private room
Correct answer: D
Rationale: When caring for a client with a C. difficile infection, it is essential to isolate them in a private room to prevent the spread of spores through contact with surfaces. Placing the client in a negative pressure room (Choice A) is not necessary for C. difficile. Using alcohol-based hand rub (Choice B) and wearing a face shield (Choice C) are important infection control measures but are not specific to the isolation requirements for C. difficile.
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