ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is planning care for a newly admitted adolescent with bacterial meningitis. What intervention should the nurse include?
- A. Initiate droplet precautions
- B. Assist the client to a supine position
- C. Perform a Glasgow Coma Scale every 24 hours
- D. Recommend prophylactic acyclovir for the client's family
Correct answer: A
Rationale: The correct intervention for a newly admitted adolescent with bacterial meningitis is to initiate droplet precautions. Bacterial meningitis is highly contagious, and droplet precautions are necessary to prevent the spread of infection. Assisting the client to a supine position (Choice B) is not directly related to managing bacterial meningitis. Performing a Glasgow Coma Scale every 24 hours (Choice C) may be important to assess the client's neurological status but is not the priority intervention in preventing the spread of infection. Recommending prophylactic acyclovir for the client's family (Choice D) is not a standard practice in the care of a patient with bacterial meningitis.
2. A nurse is planning care for a client who has chronic renal failure. Which action should the nurse include in the plan of care?
- A. Encourage increased fluid intake
- B. Restrict protein intake to the RDA
- C. Increase dietary potassium
- D. Encourage foods high in sodium
Correct answer: B
Rationale: The correct action the nurse should include in the plan of care for a client with chronic renal failure is to restrict protein intake to the RDA. This is important because limiting protein helps reduce the buildup of waste products that the kidneys are unable to efficiently excrete. Encouraging increased fluid intake (choice A) may further burden the kidneys, increasing the risk of fluid overload. Increasing dietary potassium (choice C) is not recommended in chronic renal failure as impaired kidneys have difficulty regulating potassium levels. Encouraging foods high in sodium (choice D) is also not appropriate as excessive sodium intake can lead to fluid retention and hypertension, which are detrimental in renal failure.
3. A nurse is caring for a client with congestive heart failure. Which of the following prescriptions should the nurse anticipate?
- A. Call the provider if the respiratory rate is less than 18/min
- B. Administer a 500 mL IV bolus of 0.9% sodium chloride over 1 hour
- C. Administer enalapril 2.5 mg PO twice daily
- D. Call the provider if the client’s pulse rate is less than 80/min
Correct answer: C
Rationale: Enalapril, an ACE inhibitor, is commonly prescribed to manage hypertension and heart failure. It helps reduce the workload on the heart and prevent fluid retention. Options A, B, and D are incorrect. Option A focuses on a respiratory rate, which is not specific to heart failure management. Option B suggests administering a large IV bolus of fluid, which can worsen heart failure by increasing fluid volume. Option D addresses the pulse rate, which is not a typical parameter to monitor for heart failure specifically.
4. A nurse is caring for a toddler diagnosed with respiratory syncytial virus (RSV). Which of the following actions should the nurse take?
- A. Use a designated stethoscope when caring for the toddler
- B. Wear an N95 respirator mask
- C. Remove the disposable gown after leaving the toddler’s room
- D. Place the toddler in a room with negative air pressure
Correct answer: A
Rationale: Using a designated stethoscope is the correct action when caring for a toddler diagnosed with RSV. This measure helps prevent the spread of infection to other clients by reducing the risk of contamination. Wearing an N95 respirator mask is not necessary for routine care of a toddler with RSV unless performing aerosol-generating procedures. Removing the disposable gown after leaving the toddler's room is important for infection control but not specific to RSV care. Placing the toddler in a room with negative air pressure is not a standard practice for managing RSV in toddlers.
5. A patient is receiving chemotherapy and reports nausea. Which of the following dietary recommendations should the nurse make?
- A. Eat foods served hot
- B. Drink liquids between meals
- C. Eat dry cereal
- D. Choose foods with a strong aroma
Correct answer: C
Rationale: The correct recommendation for a patient receiving chemotherapy and experiencing nausea is to suggest eating dry, bland foods like cereal. These types of foods are often better tolerated as they are less likely to trigger nausea compared to aromatic or hot foods. Drinking liquids between meals, as suggested in option B, can be helpful to prevent dehydration but may not specifically address the nausea. Eating foods with a strong aroma, as in option D, may actually worsen nausea in patients undergoing chemotherapy.
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