ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. When planning to discharge a client receiving home oxygen therapy, which of the following instructions should the nurse include in the discharge teaching?
- A. Ensure that electrical cords are not frayed
- B. Keep oxygen tanks in a horizontal position
- C. Store extra oxygen tanks in a closed closet
- D. Apply petroleum-based gel to the inside of the nostrils
Correct answer: A
Rationale: The correct answer is to ensure that electrical cords are not frayed. Frayed electrical cords pose a fire hazard when oxygen is in use. Keeping oxygen tanks in a horizontal position (Choice B) is important to prevent leaks but is not the priority compared to fire safety. Storing extra oxygen tanks in a closed closet (Choice C) is also important but not as immediate as preventing fire hazards. Applying petroleum-based gel to the inside of the nostrils (Choice D) is unrelated to oxygen therapy safety and is not recommended.
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 who is experiencing alcohol withdrawal. Which of the following interventions should the nurse implement?
- A. Encourage frequent ambulation
- B. Administer lorazepam
- C. Provide a low-calorie diet
- D. Administer insulin as prescribed
Correct answer: B
Rationale: The correct intervention for a client experiencing alcohol withdrawal is to administer lorazepam. Lorazepam, a benzodiazepine, is commonly used to manage the symptoms of alcohol withdrawal by preventing seizures and reducing agitation and anxiety. Encouraging frequent ambulation (choice A) may not be safe during alcohol withdrawal due to potential instability and confusion. Providing a low-calorie diet (choice C) is not a priority during alcohol withdrawal, as the focus is on managing withdrawal symptoms. Administering insulin as prescribed (choice D) is unrelated to managing alcohol withdrawal symptoms.
4. A home health nurse is carefully planning care for a client with Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Place a daily calendar in the kitchen
- B. Replace buttoned clothing with zippered items
- C. Replace carpet with hardwood floors
- D. Create variation in the daily routine
Correct answer: A
Rationale: Placing a daily calendar in the kitchen is essential for clients with Alzheimer's disease as it helps in orienting them to time and day, providing structure, and minimizing confusion in their daily routine. This action supports cognitive function and independence. Choice B is incorrect as it does not directly address cognitive orientation. Choice C is not a priority in the care plan and may not significantly impact the client's daily functioning. Choice D, creating variation in the daily routine, can actually increase confusion and anxiety in clients with Alzheimer's disease who thrive on predictability and structure.
5. A nurse is providing discharge teaching to a client with heart failure and a prescription for furosemide 20 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?
- A. Monitor for increased blood pressure
- B. Increase intake of high-potassium foods
- C. Expect an increase in swelling in the hands and feet
- D. Take the second dose at bedtime
Correct answer: B
Rationale: The correct answer is B: "Increase intake of high-potassium foods." Furosemide is a loop diuretic that can lead to hypokalemia, a condition characterized by low potassium levels. To prevent this adverse effect, the client should increase their intake of high-potassium foods. Choice A is incorrect because furosemide typically leads to decreased blood pressure, not increased. Choice C is incorrect because furosemide is used to reduce swelling, not increase it. Choice D is incorrect because the second dose of furosemide should be taken in the morning to prevent nocturia.
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