ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is planning to administer epoetin alfa to a client who has chronic kidney failure. Which of the following data should the nurse plan to review prior to administration of this medication?
- A. Blood pressure
- B. Temperature
- C. Blood glucose levels
- D. Total protein levels
Correct answer: A
Rationale: The correct answer is A: Blood pressure. Epoetin alfa can increase blood pressure, especially in clients with chronic kidney failure. Monitoring blood pressure before administration is crucial to prevent hypertension. Reviewing temperature, blood glucose levels, or total protein levels is not directly related to the potential side effect of increased blood pressure associated with epoetin alfa.
2. A nurse is providing teaching to a client who has cirrhosis and a new prescription for lactulose. The nurse should instruct the client that lactulose has which of the following therapeutic effects?
- A. Increases blood pressure
- B. Prevents esophageal bleeding
- C. Decreases heart rate
- D. Reduces ammonia levels
Correct answer: D
Rationale: The correct answer is D: Reduces ammonia levels. Lactulose is used to reduce blood ammonia levels in clients with hepatic encephalopathy. Options A, B, and C are incorrect because lactulose does not have the therapeutic effect of increasing blood pressure, preventing esophageal bleeding, or decreasing heart rate.
3. A nurse is reviewing the laboratory values for a client who is receiving a continuous IV heparin infusion and has an aPTT of 90 seconds. Which of the following actions should the nurse prepare to take?
- A. Administer vitamin K
- B. Reduce the infusion rate
- C. Give the client a low-dose aspirin
- D. Request an INR
Correct answer: B
Rationale: An aPTT of 90 seconds is elevated, indicating a risk of bleeding due to excessive anticoagulation. The appropriate action is to reduce the infusion rate of heparin to prevent further complications. Administering vitamin K is not indicated for an elevated aPTT due to heparin therapy. Giving the client a low-dose aspirin can further increase the risk of bleeding when combined with heparin. Requesting an INR is not necessary for monitoring heparin therapy; aPTT is the more specific test for assessing heparin's therapeutic effect. Therefore, the correct action for the nurse to prepare to take is to reduce the infusion rate of heparin.
4. A nurse is preparing to administer heparin 8,000 units subcutaneously every eight hours. The amount available is heparin injection 10,000 units/mL. How many milliliters should the nurse administer per dose? (Round the answer to the nearest tenth)
- A. 0.8 mL
- B. 0.9 mL
- C. 10.0 mL
- D. 98.0 mL
Correct answer: A
Rationale: To determine the volume of heparin to administer per dose, divide the prescribed dose (8,000 units) by the concentration of heparin available (10,000 units/mL). 8000 units / 10000 units/mL = 0.8 mL. Therefore, the nurse should administer 0.8 mL per dose. Choice B, 0.9 mL, is incorrect as the correct calculation results in 0.8 mL. Choices C and D are significantly higher and incorrect, indicating an inaccurate calculation.
5. A nurse is caring for an older adult client who has a prescription for zolpidem at bedtime to promote sleep. The nurse should plan to monitor the client for which of the following adverse effects?
- A. Ecchymosis
- B. Decreased urine output
- C. Increased blood pressure
- D. Dizziness
Correct answer: D
Rationale: The correct answer is D: Dizziness. Zolpidem is known to cause dizziness, especially in older adults. This adverse effect can increase the risk of falls and injuries in the elderly population. Monitoring for dizziness is crucial to ensure patient safety. Choice A, Ecchymosis, is the development of bruising and is not a common adverse effect of zolpidem. Choices B and C, Decreased urine output and Increased blood pressure, are not typically associated with zolpidem use. Therefore, they are incorrect choices in this scenario.