ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A client wearing an arm cast reports numb fingers. Which of the following actions should the nurse take first?
- A. Place the arm in a dependent position
- B. Administer pain medication
- C. Check the client's circulation
- D. Apply a warm compress to the fingers
Correct answer: C
Rationale: The correct answer is to check the client's circulation. Numbness in the fingers may indicate compromised circulation or nerve damage. By assessing the circulation first, the nurse can ensure that the cast is not too tight, which could be cutting off blood flow. Option A is incorrect because placing the arm in a dependent position may worsen circulation issues. Option B is incorrect as administering pain medication does not address the underlying cause of numbness. Option D is incorrect as applying a warm compress could mask circulation issues and is not the priority in this situation.
2. 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.
3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?
- A. Prealbumin level of 20 mg/dL
- B. Weight increase of 2 kg/day
- C. Temperature of 37.6°C
- D. Blood glucose level of 120 mg/dL
Correct answer: B
Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.
4. A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?
- A. Lower back pain
- B. Shortness of breath
- C. Decreased fetal movement
- D. Nausea and vomiting
Correct answer: A
Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery. Shortness of breath (Choice B), decreased fetal movement (Choice C), and nausea and vomiting (Choice D) can be common during pregnancy but are not typically associated with preterm labor. While they should be monitored, they are not immediate signs of concern for preterm labor.
5. 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.
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