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 healthcare provider is caring for a client receiving total parenteral nutrition (TPN). Which of the following should the healthcare provider monitor?
- A. Serum glucose levels
- B. Serum potassium levels
- C. Blood pressure
- D. Both A and B
Correct answer: D
Rationale: When caring for a client receiving total parenteral nutrition (TPN), monitoring serum glucose levels is essential due to the impact TPN can have on glucose metabolism. Additionally, electrolytes like potassium should be monitored as they can be affected by TPN administration. Blood pressure monitoring is not directly related to TPN administration, making choices A and B the correct options to monitor in this scenario.
3. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?
- A. Decreased deep tendon reflexes
- B. Positive Trousseau’s sign
- C. Hypoactive bowel sounds
- D. Sticky mucous membranes
Correct answer: A
Rationale: A sodium level of 122 mEq/L indicates hyponatremia, which is characterized by decreased deep tendon reflexes. Hyponatremia leads to neurological symptoms such as altered reflexes. Choices B, C, and D are not typically associated with hyponatremia. Positive Trousseau’s sign is related to hypocalcemia, hypoactive bowel sounds can be seen in paralytic ileus or decreased peristalsis, and sticky mucous membranes are not specific findings related to sodium imbalances.
4. A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?
- A. Assault
- B. Battery
- C. Negligence
- D. False imprisonment
Correct answer: C
Rationale: The correct answer is C: Negligence. Negligence refers to the failure to take reasonable care or fulfill a duty, which can cause harm to others. In this scenario, the nurse's failure to notify the provider of a change in the client's condition constitutes negligence as it breaches the standard of care expected in healthcare practice. Choice A, Assault, involves the threat of harmful or offensive contact, which is not applicable in this situation. Choice B, Battery, refers to the intentional harmful or offensive touching of another person without their consent, which is also not relevant here. Choice D, False imprisonment, involves the intentional confinement or restraint of an individual against their will, which is not the issue described in the scenario. Therefore, the most appropriate tort in this case is negligence.
5. A client has been prescribed enoxaparin. Which of the following instructions should the nurse provide regarding self-administration?
- A. Pinch the skin and inject at a 45-degree angle
- B. Massage the injection site after administering
- C. Administer at a 90-degree angle
- D. Avoid rotating injection sites
Correct answer: A
Rationale: The correct answer is to pinch the skin and inject at a 45-degree angle when administering enoxaparin. This technique helps ensure proper administration of the medication. Massaging the injection site after administering is unnecessary and could increase the risk of bleeding. Administering at a 90-degree angle is not recommended for enoxaparin injections. Rotating injection sites is important to prevent tissue damage and irritation.
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