ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A healthcare professional is preparing to administer a dose of naloxone. Which of the following should the healthcare professional assess?
- A. Heart rate
- B. Respiratory rate
- C. Blood pressure
- D. Temperature
Correct answer: B
Rationale: Correct. Naloxone is used to reverse opioid overdose, which can cause respiratory depression. Assessing the respiratory rate before administering naloxone is crucial to monitor the patient's breathing. Choices A, C, and D are important assessments in general patient care but are not specifically crucial before administering naloxone for opioid overdose.
2. A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea. Which of the following information should the nurse include in the teaching?
- A. It delivers a preset amount of inspiratory pressure at the beginning of each breath
- B. It has a continuous adjustment feature that changes the airway pressure throughout the cycle
- C. It delivers a preset amount of airway pressure throughout the breathing cycle
- D. It delivers positive pressure at the end of each breath
Correct answer: C
Rationale: The correct information that the nurse should include in the teaching about a CPAP device is that it delivers a preset amount of airway pressure throughout the breathing cycle. This consistent positive airway pressure helps keep the airway open during both inspiration and expiration. Choice A is incorrect as CPAP does not deliver pressure only at the beginning of each breath. Choice B is incorrect because CPAP provides a constant level of pressure without continuous adjustments throughout the cycle. Choice D is incorrect as CPAP does not provide positive pressure at the end of each breath; instead, it maintains a continuous positive pressure.
3. A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?
- A. You should keep the car seat rear-facing until your baby is at least 2 years old.
- B. Position the retainer clip over the upper part of your baby's abdomen.
- C. You should place your baby in the car seat with a slight recline.
- D. Place the shoulder harness straps in the slots at or below your baby's shoulders.
Correct answer: A
Rationale: The correct answer is A. The car seat should remain rear-facing until the baby is at least 2 years old to ensure maximum safety in the event of a collision. This position helps protect the infant’s head, neck, and spine. Choice B is incorrect because the retainer clip should be positioned at armpit level on the baby, not over the upper part of the abdomen. Choice C is incorrect as the baby should be placed in the car seat with a slight recline, not at a 90-degree angle. Choice D is incorrect as the shoulder harness straps should be at or below the baby's shoulders, not above, to ensure proper fit and safety.
4. A nurse is teaching a newly licensed nurse about contraindications to ceftriaxone. The nurse should include a severe allergy to which of the following medications as a contraindication to ceftriaxone?
- A. Gentamicin
- B. Clindamycin
- C. Piperacillin
- D. Sulfamethoxazole-trimethoprim
Correct answer: C
Rationale: Ceftriaxone is a cephalosporin, and individuals with a penicillin allergy (such as Piperacillin) may have cross-sensitivity, making it contraindicated. Gentamicin (Choice A) belongs to the aminoglycoside class, not related to cephalosporins. Clindamycin (Choice B) is a lincosamide antibiotic and is not typically associated with cross-allergies to cephalosporins. Sulfamethoxazole-trimethoprim (Choice D) is a sulfonamide antibiotic, also not directly related to ceftriaxone.
5. A client tells the nurse that she suspects she is pregnant because she is able to feel the baby move. The nurse knows that this is a:
- A. Presumptive sign of pregnancy
- B. Probable sign of pregnancy
- C. Positive sign of pregnancy
- D. Possible sign of pregnancy
Correct answer: A
Rationale: The correct answer is A: Presumptive sign of pregnancy. Quickening, or the sensation of fetal movement, is considered a presumptive sign of pregnancy. It is not definitive because other conditions, such as gas or intestinal movement, can mimic the feeling of fetal movement. Choice B, Probable sign of pregnancy, refers to signs that make the nurse reasonably certain that a woman is pregnant, such as a positive pregnancy test. Choice C, Positive sign of pregnancy, includes signs like hearing fetal heart tones or visualizing the fetus on ultrasound, which definitively confirm pregnancy. Choice D, Possible sign of pregnancy, is a vague term and does not specifically relate to any pregnancy sign.
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