ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A nurse is preparing to administer a dose of digoxin. Which of the following should the nurse do first?
- A. Assess blood pressure
- B. Check heart rate
- C. Monitor potassium levels
- D. Review the medication order
Correct answer: B
Rationale: The correct answer is to check the heart rate first before administering digoxin. Digoxin is a medication that directly affects the heart, so it is crucial to ensure that the heart rate is within the appropriate range before giving the dose. If the heart rate is below 60 bpm, administering digoxin could lead to toxicity. Assessing blood pressure (Choice A) is important but not the first priority when preparing to administer digoxin. Monitoring potassium levels (Choice C) is also crucial for patients on digoxin, but it is not the initial step. Reviewing the medication order (Choice D) is necessary but can be done after checking the heart rate.
2. How can the nurse best advocate for a patient who will be discharged from acute care to home?
- A. Arranging for Meals on Wheels to provide in-home meals
- B. Administering pain medication prior to discharge
- C. Teaching the patient how to take medications at home
- D. Taking the patient by wheelchair to the car
Correct answer: A
Rationale: Arranging for in-home support services like Meals on Wheels is crucial for ensuring the patient receives proper nutrition and support after discharge. This goes beyond simply administering medications or providing transportation. By arranging for in-home meals, the nurse addresses the patient's nutritional needs, promotes their overall well-being, and supports their ongoing care requirements. Administering pain medication or teaching medication management, while important, do not directly address the patient's need for nutritional support. Taking the patient by wheelchair to the car is focused on physical transportation and does not encompass the holistic care approach needed for a successful transition to home care.
3. During an admission physical assessment, the nurse is examining a newborn who is small for gestational age (SGA). Which finding should the nurse report immediately to the pediatric healthcare provider?
- A. Heel stick glucose of 65 mg/dL.
- B. Head circumference of 35 cm (14 inches).
- C. Widened, tense, bulging fontanel.
- D. High-pitched shrill cry.
Correct answer: C
Rationale: A widened, tense, bulging fontanel is a critical finding in a newborn as it can indicate increased intracranial pressure. This condition requires immediate attention and intervention to prevent further complications. Monitoring fontanel status is crucial in assessing the newborn's neurological well-being and ensuring early detection of potential issues.
4. A nurse is planning care for a newly admitted adolescent client who has bacterial meningitis. Which of the following instructions is appropriate for the nurse to include in the plan of care?
- A. Initiate droplet precautions
- B. Assist the client to a supine position
- C. Perform Glasgow Coma Scale assessment every 24 hours
- D. Recommend prophylactic acyclovir for the client’s family
Correct answer: A
Rationale: The correct answer is A: 'Initiate droplet precautions.' Bacterial meningitis requires droplet precautions to prevent the spread of infection, as the bacteria can be transmitted through respiratory secretions. Choice B is incorrect because assisting the client to a supine position is not specific to the care of a client with bacterial meningitis and may not be appropriate for all clients. Choice C is incorrect because while performing Glasgow Coma Scale assessments is important in managing clients with neurological conditions, it is not directly related to preventing the spread of bacterial meningitis. Choice D is incorrect because recommending prophylactic acyclovir for the client's family is not a standard precautionary measure for preventing the spread of bacterial meningitis.
5. Which of the following is an example of a cognitive-behavioral therapy (CBT) technique?
- A. Free association
- B. Thought stopping
- C. Dream analysis
- D. Systematic desensitization
Correct answer: B
Rationale: Thought stopping is a specific cognitive-behavioral therapy (CBT) technique aimed at helping individuals manage and interrupt negative or intrusive thoughts. This technique involves identifying and stopping negative thought patterns to promote healthier thinking and emotional well-being. Free association and dream analysis are associated with psychoanalytic therapy, while systematic desensitization is a technique commonly used in behavior therapy.
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