ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A nurse is preparing to administer a dose of losartan. Which of the following should the nurse assess first?
- A. Blood pressure
- B. Heart rate
- C. Serum potassium
- D. Liver function
Correct answer: A
Rationale: The correct answer is to assess blood pressure first. Losartan is an angiotensin receptor blocker used to lower blood pressure. Assessing the patient's blood pressure before administering losartan is crucial to ensure it is not already too low, which could lead to hypotension. Assessing heart rate (choice B) is important but not the priority when administering losartan. Serum potassium levels (choice C) and liver function (choice D) are also important assessments, but they are not the primary concern before administering losartan.
2. A newborn demonstrates respiratory distress, and routine suctioning with the bulb syringe is unsuccessful. What is the next nursing intervention?
- A. Initiate chest compressions
- B. Administer oxygen
- C. Suction with a mechanical device
- D. Notify the healthcare provider
Correct answer: C
Rationale: When routine suctioning with a bulb syringe is unsuccessful in a newborn demonstrating respiratory distress, the next appropriate nursing intervention is to suction with a mechanical device. This method ensures effective removal of any airway obstruction. Initiating chest compressions (Choice A) is not indicated in this scenario as the primary concern is airway clearance. Administering oxygen (Choice B) may be necessary, but addressing the airway obstruction should take precedence. Notifying the healthcare provider (Choice D) can be considered after attempting mechanical suction if the newborn's condition does not improve.
3. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?
- A. Inflate the balloon with 10 mL of sterile water prior to insertion
- B. Cleanse the client’s labia and meatus using a front-to-back motion
- C. Ask the client to bear down while inserting the catheter
- D. Inflate the catheter balloon after urine begins to flow
Correct answer: D
Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.
4. A healthcare professional is preparing to administer a dose of potassium chloride. Which of the following should the professional do?
- A. Administer it as a bolus
- B. Dilute the medication
- C. Give it rapidly
- D. Monitor respiratory rate
Correct answer: B
Rationale: Correct Answer: Dilute the medication. Potassium chloride should always be diluted before administration to avoid irritation and complications. Choice A is incorrect because administering it as a bolus can lead to adverse effects. Choice C is incorrect as giving it rapidly can be dangerous. Choice D is incorrect as monitoring the respiratory rate is not directly related to administering potassium chloride.
5. A client prescribed allopurinol for gout is being taught by a nurse. Which of the following should be included in the teaching?
- A. Take the medication with meals.
- B. Drink at least 2 liters of water per day.
- C. Avoid foods high in purines.
- D. Increase your dietary intake of calcium.
Correct answer: B
Rationale: The correct answer is B: 'Drink at least 2 liters of water per day.' Clients taking allopurinol should be instructed to drink plenty of water to prevent kidney stones, a potential side effect of the medication. Option A is incorrect because allopurinol is usually taken without regard to meals. Option C is not directly related to the teaching about allopurinol, as it pertains more to dietary management of gout. Option D is also unrelated to allopurinol use for gout.
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