ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A client with a seizure disorder has a new prescription for valproic acid. Which of the following laboratory values should the nurse plan to monitor? (Select all that apply)
- A. PTT
- B. Aspartate aminotransferase (AST)
- C. Alanine aminotransferase (ALT)
- D. All of the Above
Correct answer: D
Rationale: The correct answer is D, 'All of the Above.' Valproic acid can impact liver function and coagulation. Monitoring the Prothrombin Time (PTT), Aspartate Aminotransferase (AST), and Alanine Aminotransferase (ALT) is crucial. PTT is monitored to assess coagulation status, while AST and ALT are liver enzymes that indicate liver function. Monitoring these values helps detect any potential adverse effects of valproic acid on the liver and blood clotting. Choices A, B, and C are incorrect because each of these laboratory values plays a critical role in evaluating the client's response to valproic acid therapy and detecting associated complications.
2. A nurse is reviewing the medical history of a client with dementia. Which of the following findings should the nurse address first?
- A. Restlessness and agitation
- B. Decreased respiratory rate
- C. Wandering during the night
- D. Incontinence
Correct answer: A
Rationale: In a client with dementia, addressing restlessness and agitation is a priority because these symptoms can exacerbate dementia and lead to further complications. Restlessness and agitation can indicate underlying issues such as pain, discomfort, or unmet needs, which should be promptly assessed and managed to improve the client's quality of life. Decreased respiratory rate, wandering during the night, and incontinence are important to address but do not pose immediate risks to the client's well-being compared to the potential effects of unmanaged restlessness and agitation in dementia.
3. When covering another nurse's assignment during a lunch break, based on the status report provided, which client should the charge nurse check first?
- A. The client admitted yesterday with diabetic ketoacidosis whose blood glucose level is now 195 mg/dl.
- B. The client with an ileal conduit created two days ago with a scant amount of blood in the drainage pouch.
- C. The client post-triple coronary bypass four days ago who has serosanguinous drainage in the chest tube.
- D. The client with a pneumothorax secondary to a gunshot wound with a current pulse oximeter reading of 90%.
Correct answer: D
Rationale: The client with a pneumothorax and a pulse oximeter reading of 90% indicates potential respiratory compromise, requiring immediate attention to prevent further deterioration.
4. A client in active labor reports back pain while being examined by a nurse who finds her to be 8 cm dilated, 100% effaced, -2 station, and in the occiput posterior position. What action should the nurse take?
- A. Perform effleurage during contractions.
- B. Place the client in lithotomy position.
- C. Assist the client to the hands and knees position.
- D. Apply a scalp electrode to the fetus.
Correct answer: C
Rationale: The nurse should assist the client into the hands and knees position during contractions to help relieve her back pain and facilitate the rotation of the fetus from the posterior to an anterior occiput position. This position can aid in optimal fetal positioning for delivery. Choice A, performing effleurage, is a massage technique that may provide comfort but does not address the fetal position. Placing the client in lithotomy position (Choice B) may not be ideal for a client experiencing back pain due to the occiput posterior position. Applying a scalp electrode to the fetus (Choice D) is not indicated solely for addressing the client's back pain.
5. While caring for a client receiving nitroglycerin for chest pain, which of the following side effects should the nurse monitor for?
- A. Hypotension
- B. Tachycardia
- C. Bradycardia
- D. Hyperglycemia
Correct answer: A
Rationale: Corrected Rationale: Nitroglycerin is known to cause hypotension due to its vasodilating effect, which can lead to low blood pressure. Therefore, the nurse should closely monitor the client for signs of hypotension such as dizziness, light-headedness, or weakness. Tachycardia (increased heart rate), bradycardia (decreased heart rate), and hyperglycemia (high blood sugar) are not typically associated with nitroglycerin use and are less likely to be side effects that the nurse needs to monitor for in this scenario.