ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A nurse is preparing to administer prochlorperazine 2.5 mg IV. Available is prochlorperazine injection 5 mg/mL. How many mL should the nurse administer?
- A. 0.2 mL
- B. 0.5 mL
- C. 1.0 mL
- D. 1.5 mL
Correct answer: B
Rationale: To determine the volume of prochlorperazine to administer, divide the prescribed dose (2.5 mg) by the concentration of the medication (5 mg/mL). This calculation results in 0.5 mL. Therefore, the nurse should administer 0.5 mL to deliver the correct dose. Choice A (0.2 mL) is incorrect as it miscalculates the dosage. Choices C (1.0 mL) and D (1.5 mL) are also incorrect as they do not accurately reflect the calculated volume needed for the dose.
2. A client with a history of deep vein thrombosis (DVT) is receiving warfarin (Coumadin). Which instruction should the nurse provide?
- A. Avoid green leafy vegetables.
- B. Take aspirin for headaches.
- C. Use a soft-bristled toothbrush.
- D. Limit fluid intake to 1 liter per day.
Correct answer: C
Rationale: The correct instruction for a client on warfarin therapy, especially with a history of DVT, is to use a soft-bristled toothbrush. This is crucial to prevent gum bleeding, which is a risk due to the anticoagulant effects of warfarin. Green leafy vegetables are rich in vitamin K, which can interfere with warfarin's effectiveness, so they should be consumed consistently to maintain a balance. Aspirin is not recommended for headaches in clients on warfarin due to the increased risk of bleeding. Limiting fluid intake is not a standard instruction for clients on warfarin therapy.
3. When teaching a client about the proper use of a cane, which of the following instructions should be included?
- A. Hold the cane on the weaker side.
- B. Move the cane forward first.
- C. Keep the cane 12 inches away from the body.
- D. Use the cane for support only when climbing stairs.
Correct answer: B
Rationale: When using a cane, it is crucial to move the cane forward first to provide support and enhance balance. Advancing the cane before the weaker or stronger leg helps widen the base of support, thereby improving stability during ambulation. Keeping the cane too far or too close to the body can affect its supportive function. Moreover, utilizing the cane solely for stair climbing limits its overall utility in maintaining balance and stability during regular walking.
4. For which of the following is informed consent required?
- A. Ordering a liquid diet for a post-surgical patient
- B. Listening to a patient reveal his or her private, personal secrets
- C. Giving a patient saline solution to relieve dry nasal passages
- D. Asking a patient to complete a questionnaire for a research study on hospital practices
Correct answer: D
Rationale: Informed consent is required when asking a patient to participate in a research study, as mentioned in choice D. Choices A, B, and C involve routine care measures that do not require specific informed consent. Ordering a liquid diet, providing saline solution for dry nasal passages, or listening to a patient's personal secrets are part of standard care and do not typically necessitate formal consent beyond general consent for treatment.
5. What assessments should the nurse prioritize for a client with portal hypertension admitted to the medical floor?
- A. Assessment of blood pressure and evaluation for headaches and visual changes
- B. Assessment for signs and symptoms of venous thromboembolism
- C. Daily weights and measurement of abdominal girth
- D. Monitoring blood glucose every 4 hours
Correct answer: C
Rationale: In portal hypertension, daily weights and measurement of abdominal girth are crucial assessments to monitor fluid retention and ascites. These assessments help in evaluating the effectiveness of treatment and identifying any worsening of the condition, guiding appropriate interventions. Monitoring blood pressure and assessing for symptoms like headaches and visual changes may be important but are not the priority in this case. Assessing for signs and symptoms of venous thromboembolism is relevant in some situations but not directly related to the primary concerns of portal hypertension.
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