ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is preparing to feed a newly admitted client with dysphagia. Which of the following actions should the nurse take?
- A. Instruct the client to lift their chin when swallowing
- B. Discourage the client from coughing during feedings
- C. Sit at or below the client’s eye level during feedings
- D. Talk with the client during feedings
Correct answer: C
Rationale: The correct answer is C. Sitting at or below the client’s eye level is important when feeding a client with dysphagia. This position allows the nurse to closely observe the client for any signs of difficulty with swallowing, which can help prevent aspiration. Instructing the client to lift their chin when swallowing (choice A) is not recommended for clients with dysphagia as it can increase the risk of aspiration. Discouraging the client from coughing during feedings (choice B) is also not correct, as coughing may be a protective mechanism to prevent aspiration. Talking with the client during feedings (choice D) may distract the client and interfere with their ability to focus on swallowing safely.
2. A nurse is providing teaching to a client who has tuberculosis (TB) and is prescribed rifampin. Which of the following statements should the nurse include in the teaching?
- A. This medication can cause your urine to turn a reddish-orange color.
- B. You should expect to take this medication for at least 6 months.
- C. You should avoid eating dairy products while on this medication.
- D. This medication can cause sensitivity to sunlight.
Correct answer: A
Rationale: The correct answer is A. Rifampin can cause harmless red-orange discoloration of bodily fluids, including urine, sweat, and tears. Clients should be informed about this side effect. Choice B is incorrect because the duration of rifampin therapy for TB is typically longer than 6 months. Choice C is incorrect as there is no need to avoid dairy products while on rifampin. Choice D is incorrect as rifampin does not cause sensitivity to sunlight.
3. A healthcare provider is caring for a client with severe preeclampsia. Which of the following medications should the healthcare provider anticipate administering?
- A. Magnesium sulfate
- B. Oxytocin
- C. Misoprostol
- D. Nifedipine
Correct answer: A
Rationale: Magnesium sulfate is the correct answer as it is administered to prevent seizures in clients with severe preeclampsia. It acts as a central nervous system depressant and is the first-line treatment for eclampsia prevention. Oxytocin (Choice B) is used to induce or augment labor, not indicated specifically for preeclampsia. Misoprostol (Choice C) is used for labor induction and postpartum hemorrhage, not typically indicated for preeclampsia. Nifedipine (Choice D) is a calcium channel blocker used for managing hypertension in pregnancy but is not the first-line treatment for preventing seizures in severe preeclampsia.
4. While receiving a change of shift report on a group of clients, which patient should the nurse assess first?
- A. The client who has a fractured femur and reports sharp chest pain.
- B. The client who has a fever and is receiving antibiotics.
- C. The client who has a urinary tract infection and reports pain with urination.
- D. The client who is scheduled for surgery in the afternoon.
Correct answer: A
Rationale: The nurse should assess the client with a fractured femur and sharp chest pain first. Sharp chest pain in this client may indicate a pulmonary embolism, a life-threatening condition requiring immediate attention. The other options describe important patient conditions but do not pose an immediate threat to life like a potential pulmonary embolism does.
5. A client with multiple sclerosis reports diplopia. Which of the following actions should the nurse take?
- A. Encourage the client to focus on a distant object.
- B. Apply a warm compress to the client’s eyes.
- C. Recommend alternating eye patches during the day.
- D. Administer artificial tears.
Correct answer: C
Rationale: The correct action for the nurse to take when caring for a client with multiple sclerosis reporting diplopia is to recommend alternating eye patches during the day. This strategy can help relieve diplopia (double vision) by allowing each eye to rest alternately, reducing eye strain. Encouraging the client to focus on a distant object (Choice A) is not an appropriate intervention for diplopia in this case. Applying a warm compress to the client's eyes (Choice B) and administering artificial tears (Choice D) are not effective interventions for diplopia associated with multiple sclerosis.
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