ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A healthcare professional is preparing to administer a dose of warfarin. Which of the following actions should the healthcare professional take?
- A. Verify INR levels
- B. Administer with food
- C. Monitor blood glucose levels
- D. Assess liver function
Correct answer: A
Rationale: Corrected Rationale: When administering warfarin, it is crucial to verify the patient's INR levels. INR monitoring is essential to ensure that the patient is receiving the correct dose of warfarin for their condition and to minimize the risk of bleeding. Choices B, C, and D are incorrect because administering warfarin with food, monitoring blood glucose levels, and assessing liver function are not directly related to the safe administration and monitoring of warfarin therapy.
2. A nurse is caring for a client who has preeclampsia and is receiving magnesium sulfate. Which action should the nurse take if the client develops toxicity?
- A. Administer calcium gluconate IV
- B. Increase the magnesium sulfate infusion
- C. Administer IV fluids
- D. Administer hydralazine
Correct answer: A
Rationale: In cases of magnesium sulfate toxicity, administering calcium gluconate IV is crucial as it is the antidote for magnesium sulfate. Calcium gluconate helps reverse the effects of magnesium sulfate, especially when signs of toxicity like respiratory depression or loss of reflexes occur. Increasing the magnesium sulfate infusion would worsen toxicity. Administering IV fluids may be beneficial for hydration but does not address magnesium sulfate toxicity. Hydralazine is used to manage hypertension, not magnesium sulfate toxicity.
3. A nurse is providing discharge teaching to a client with a new prescription for furosemide. Which client statement indicates a need for further teaching?
- A. I will take my morning pills with food or milk.
- B. I will weigh myself every day.
- C. I will notify the nurse if I have muscle cramps.
- D. I will limit my intake of fish.
Correct answer: D
Rationale: The correct answer is D. Furosemide is a diuretic that does not require a reduction in fish consumption. Therefore, the statement 'I will limit my intake of fish' indicates a misunderstanding of dietary considerations. Choices A, B, and C are all appropriate actions related to furosemide therapy. Taking pills with food or milk can help reduce stomach upset, daily weight monitoring is crucial due to the diuretic effect of furosemide, and notifying the nurse about muscle cramps is important as it can be a sign of electrolyte imbalance, a potential side effect of furosemide.
4. A nurse is providing teaching to a client who has a new prescription for lisinopril. Which of the following statements by the client indicates a need for further teaching?
- A. I will notify my doctor if I develop a cough.
- B. I will avoid using salt substitutes.
- C. I will increase my intake of potassium-rich foods.
- D. I will monitor my blood pressure regularly.
Correct answer: C
Rationale: The correct answer is C. Clients taking lisinopril should avoid potassium-rich foods because ACE inhibitors can increase potassium levels, potentially leading to hyperkalemia. Choices A, B, and D are all correct statements. Clients should notify their doctor if they develop a cough as it can indicate a potential side effect of lisinopril. Avoiding salt substitutes is important as they may contain potassium chloride, which can also raise potassium levels. Monitoring blood pressure regularly is essential when taking an antihypertensive medication like lisinopril.
5. A client is prescribed insulin glargine. Which of the following should the nurse instruct the client to do regarding administration of this medication?
- A. Inject insulin glargine 30 minutes before a meal.
- B. Shake the insulin vial before administration.
- C. Administer insulin glargine once daily at bedtime.
- D. Take insulin glargine with short-acting insulin.
Correct answer: C
Rationale: The correct answer is C: Administer insulin glargine once daily at bedtime. Insulin glargine is a long-acting insulin that provides a basal level of insulin throughout the day. It should be given at the same time each day, usually at bedtime, to maintain a consistent blood sugar level. Choices A, B, and D are incorrect. Injecting insulin glargine before a meal (Choice A) is not necessary as it is a long-acting insulin. Shaking the insulin vial (Choice B) is not recommended as it may cause bubbles to form, affecting the accuracy of the dose. Taking insulin glargine with short-acting insulin (Choice D) is not a typical practice as insulin glargine is used for basal insulin coverage.
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