ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse is planning care for a client who has Parkinson’s disease and is at risk for aspiration. Which of the following actions should the nurse include in the plan of care?
- A. Encourage the client to eat thin liquids
- B. Instruct the client to tilt their head forward when swallowing
- C. Give the client large pieces of food
- D. Have the client lie down after meals
Correct answer: B
Rationale: The correct action the nurse should include in the plan of care for a client with Parkinson’s disease at risk for aspiration is to instruct the client to tilt their head forward when swallowing. This action helps protect the airway and reduces the risk of aspiration in clients with impaired swallowing, which is common in Parkinson’s disease. Encouraging the client to eat thin liquids (Choice A) can increase the risk of aspiration as they are harder to control during swallowing. Giving the client large pieces of food (Choice C) can also increase the risk of choking and aspiration. Having the client lie down after meals (Choice D) can further increase the risk of aspiration due to the potential for reflux. Therefore, the best action to prevent aspiration in this situation is to instruct the client to tilt their head forward when swallowing.
2. A nurse is caring for a client who is 8 hours postpartum following a vaginal birth. The client reports passing large clots and heavy bleeding. Which of the following actions should the nurse take?
- A. Massage the fundus
- B. Administer methylergonovine
- C. Increase the IV fluid rate
- D. Notify the healthcare provider
Correct answer: A
Rationale: Heavy bleeding and the passage of large clots after childbirth can indicate uterine atony. The nurse should first attempt to massage the fundus to stimulate uterine contractions and control the bleeding. Massaging the fundus helps the uterus to contract and may help prevent further bleeding. Administering methylergonovine (Choice B) is not the initial intervention for uterine atony. Increasing the IV fluid rate (Choice C) may not address the underlying cause of the bleeding. Notifying the healthcare provider (Choice D) can be done after attempting initial interventions like fundal massage.
3. A client who is Rh-negative is being taught about Rh (D) immune globulin by a nurse. Which statement by the client indicates an understanding of the teaching?
- A. If my partner is Rh-negative, I will not receive the shot.
- B. I will receive the shot after delivery if my baby is Rh-negative.
- C. I should not receive any immunizations for 3 months after the shot.
- D. This shot may be given after birth to protect future pregnancies.
Correct answer: D
Rationale: Choice D is the correct answer because it reflects an understanding of Rh immune globulin administration. Rh immune globulin is given after delivery to prevent sensitization in future pregnancies, particularly if the baby is Rh-positive. Choice A is incorrect because Rh-negative partners do not affect the need for Rh immune globulin. Choice B is incorrect as Rh immune globulin is given if the baby is Rh-positive, not Rh-negative. Choice C is incorrect; there is no requirement to avoid immunizations after receiving Rh immune globulin.
4. A client newly diagnosed with osteoporosis is being taught by a nurse about preventing complications. Which food should the nurse recommend?
- A. Fried chicken
- B. Whole milk
- C. Oatmeal
- D. Bacon
Correct answer: C
Rationale: Oatmeal is an excellent recommendation for clients with osteoporosis due to its richness in fiber and nutrients, making it a heart-healthy and bone-friendly choice. Fried chicken (Choice A) is high in unhealthy fats and lacks the nutrients needed for bone health. Whole milk (Choice B) contains calcium but can be high in saturated fats, which may not be the best choice for individuals with osteoporosis. Bacon (Choice D) is high in saturated fats and sodium, which can have negative effects on bone health and overall well-being.
5. A healthcare professional is reviewing the health history of an older adult who has a hip fracture. What is a risk factor for developing pressure injuries?
- A. Dehydration
- B. Urinary incontinence
- C. Poor nutrition
- D. Poor tissue perfusion
Correct answer: B
Rationale: Urinary incontinence is a risk factor for developing pressure injuries due to prolonged skin exposure to moisture and irritants. Dehydration (choice A) can contribute to skin dryness but is not a direct risk factor for pressure injuries. Poor nutrition (choice C) can affect wound healing but is not specifically linked to pressure injuries. Poor tissue perfusion (choice D) can increase the risk of tissue damage but is not as directly associated with pressure injuries as urinary incontinence.
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