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 assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?
- A. Assist the client to void
- B. Massage the uterus
- C. Administer oxytocin
- D. Encourage breastfeeding
Correct answer: A
Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.
3. A nurse is reviewing laboratory results for a client who has chronic kidney disease. Which of the following findings should the nurse expect?
- A. Hypernatremia
- B. Hypocalcemia
- C. Low potassium
- D. Low magnesium
Correct answer: B
Rationale: In chronic kidney disease, the kidneys have impaired ability to activate vitamin D, leading to decreased production of calcitriol. Calcitriol is essential for calcium absorption in the intestines. Therefore, hypocalcemia is a common finding in chronic kidney disease. Hypernatremia (increased sodium levels) is not typically associated with chronic kidney disease. Low potassium and low magnesium are possible electrolyte imbalances in chronic kidney disease, but they are not as directly related to the impaired activation of vitamin D as hypocalcemia.
4. A healthcare provider is reviewing a client’s care plan. Which of the following goals is most appropriate?
- A. Client will inject insulin twice daily
- B. Client will keep appointments with the healthcare provider for 6 months
- C. Client's A1c will be 5% within one year
- D. Client's blood glucose will stay between 60-120 mg/dL
Correct answer: C
Rationale: The correct answer is C. A1c is a key indicator of long-term diabetes management, reflecting average blood sugar levels over the past 2-3 months. Achieving a target A1c of 5% indicates good control of blood sugar levels and reduces the risk of diabetes-related complications. Choices A, B, and D are not as appropriate as they focus on short-term tasks or individual blood glucose readings, rather than long-term management and outcomes.
5. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?
- A. 1 packet of reconstituted dry onion soup
- B. 3 oz of lean cured ham
- C. 3 oz of chicken breast
- D. 1/2 cup of canned baked beans
Correct answer: C
Rationale: A low sodium diet is recommended for a client who has hypertension. Therefore, the nurse should recommend 3 oz of chicken breast as the best choice for the client's diet because it contains 30 – 90 mg of sodium. Choice A, 1 packet of reconstituted dry onion soup, and Choice B, 3 oz of lean cured ham, are high in sodium content, which is not suitable for a client with hypertension. Choice D, 1/2 cup of canned baked beans, is also high in sodium, making it a less suitable choice compared to 3 oz of chicken breast.
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