ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is providing dietary teaching to a client who is at risk for cardiovascular disease. Which of the following foods should the nurse recommend?
- A. Fried chicken
- B. Oatmeal
- C. Bacon
- D. Whole milk
Correct answer: B
Rationale: Oatmeal is high in fiber, which helps lower cholesterol levels, making it a heart-healthy food option for clients at risk for cardiovascular disease. Fried chicken, bacon, and whole milk are high in saturated fats and cholesterol, which can increase the risk of heart disease and should be limited in the diet of individuals at risk for cardiovascular issues.
2. A healthcare provider is preparing to transfer a client from a chair to the bed. The client can bear partial weight and has upper body strength. Which device should the healthcare provider use?
- A. A wheelchair
- B. A stand-assist lift
- C. A transfer belt
- D. A slide board
Correct answer: B
Rationale: A stand-assist lift is the most suitable device for transferring a client who can bear partial weight and has upper body strength. This device provides support and assistance for the client to stand up and transfer safely. Choice A, a wheelchair, is not designed for this purpose and is used for mobility. Choice C, a transfer belt, is helpful for providing stability during transfers but may not be sufficient for a client with partial weight-bearing. Choice D, a slide board, is more suitable for transferring clients who are unable to bear weight and need assistance for lateral transfers.
3. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?
- A. Dry, cracked lips
- B. Bleeding gums
- C. Foul-smelling breath
- D. Red, open sores in the mouth
Correct answer: D
Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.
4. A nurse is caring for four clients. Which of the following client data should the nurse report to the provider?
- A. Client who has pleurisy and reports pain of 6 on a scale of 0 to 10
- B. Client with 110 mL of serosanguineous fluid from a Jackson Pratt drain within the first 24 hours after surgery
- C. Client who is 4 hours postoperative and has a heart rate of 98 bpm
- D. Client who has a prescription for chemotherapy and an absolute neutrophil count of 75/mm3
Correct answer: D
Rationale: An absolute neutrophil count of 75/mm3 indicates severe neutropenia, which puts the client at high risk of infection and requires immediate intervention. Neutropenia increases the susceptibility to infections due to a significant decrease in neutrophils, which are essential for fighting off bacteria and other pathogens. Reporting this critical lab value promptly to the provider is essential to ensure appropriate interventions are initiated to prevent life-threatening infections. Choices A, B, and C do not present immediate life-threatening conditions that require urgent reporting to the provider.
5. A nurse is assessing a client who has anemia. Which of the following findings should the nurse expect?
- A. Bounding pulse
- B. Conjunctival pallor
- C. Elevated blood pressure
- D. Glossitis
Correct answer: B
Rationale: The correct answer is B: Conjunctival pallor. In anemia, there is a decrease in hemoglobin levels, leading to paleness of the conjunctiva. This is a common finding in individuals with anemia. Bounding pulse (choice A) is not typically associated with anemia but can be seen in conditions like hyperthyroidism. Elevated blood pressure (choice C) is not a common finding in anemia; instead, blood pressure may be low due to decreased oxygen-carrying capacity. Glossitis (choice D), or a swollen tongue, can be seen in certain types of anemia but is not as specific or common as conjunctival pallor.
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