ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A healthcare professional is preparing to administer a dose of hydrocodone. Which of the following should the healthcare professional assess first?
- A. Respiratory rate
- B. Blood pressure
- C. Pain level
- D. Heart rate
Correct answer: A
Rationale: When administering hydrocodone, a healthcare professional should assess the respiratory rate first because hydrocodone is an opioid that can lead to respiratory depression. Monitoring the respiratory rate helps to detect any signs of respiratory distress or depression early on. Assessing blood pressure, pain level, or heart rate is also important but not the priority when administering hydrocodone, as the risk of respiratory depression is a more critical concern.
2. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which is a contraindication for this vaccine?
- A. Recent blood transfusion
- B. Allergy to penicillin
- C. Minor acute illness
- D. Low-grade fever
Correct answer: A
Rationale: The correct answer is A: Recent blood transfusion. A recent blood transfusion can interfere with the effectiveness of the MMR vaccine, making it a contraindication. Choice B, allergy to penicillin, is not a contraindication for the MMR vaccine. Choice C, minor acute illness, is not a contraindication unless the child has a moderate to severe illness. Choice D, low-grade fever, is not a contraindication as long as the child does not have a moderate to severe febrile illness.
3. A nurse is caring for a client who has been prescribed furosemide. Which of the following foods should the nurse encourage the client to include in their diet?
- A. Table salt
- B. Egg yolks
- C. White wine
- D. Oranges
Correct answer: D
Rationale: Furosemide is a potassium-wasting diuretic, so clients should consume potassium-rich foods like oranges to prevent hypokalemia. Oranges are a good source of potassium. Table salt, egg yolks, and white wine do not provide significant amounts of potassium and are not beneficial for a client taking furosemide.
4. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?
- A. I should apply clean dressings over blood-saturated dressings and hold pressure.
- B. I will rinse the wound with hot water to cleanse it.
- C. I can remove the dressing once the bleeding stops.
- D. I should apply antibiotic ointment directly to the wound.
Correct answer: A
Rationale: The correct answer is A because applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue, aiding in the clotting process and controlling bleeding. Choice B is incorrect as rinsing a wound with hot water can cause further tissue damage. Choice C is incorrect as the dressing should not be removed once applied as it can disrupt the formation of a clot. Choice D is incorrect as antibiotic ointment should not be applied directly to the wound during initial first aid.
5. A client in respiratory distress who is on oxygen is being cared for by a nurse. What is the most appropriate short-term goal?
- A. Nasal cannula remains in place
- B. Client completes morning care
- C. Client verbalizes breathing improvement after lunch
- D. Client maintains oxygen saturation of 90% during the shift
Correct answer: D
Rationale: The correct answer is D because maintaining oxygen saturation of 90% is a specific, measurable short-term goal that ensures adequate oxygenation. Choice A is not a goal focused on the client's physiological status but rather on the equipment. Choice B is related to activities of daily living and does not address the respiratory distress issue. Choice C is subjective and may not reflect the actual physiological improvement in the client's condition.
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