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 client has a stage 1 pressure ulcer on the right heel. Which of the following interventions should the nurse include in the plan?
- A. Apply a heat lamp to the area for 20 minutes each day.
- B. Change the dressing on the heel every 12 hours.
- C. Apply a transparent dressing over the heel.
- D. Use a water pressure mattress.
Correct answer: C
Rationale: Applying a transparent dressing over the heel is beneficial as it can protect the ulcer from friction and shear, and allow for continuous observation of the wound. This intervention promotes healing and prevents further damage to the skin. Choice A is incorrect because applying heat can increase the risk of tissue damage and should be avoided. Choice B is incorrect as changing the dressing every 12 hours may disrupt the wound healing process and is not necessary for a stage 1 pressure ulcer. Choice D is incorrect because using a water pressure mattress is not a specific intervention for a stage 1 pressure ulcer on the heel.
3. The client is receiving furosemide (Lasix) for heart failure. What potential side effect should the nurse monitor for?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hypernatremia
- D. Hypoglycemia
Correct answer: A
Rationale: The correct answer is A: Hypokalemia. Furosemide, a loop diuretic, causes potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial because hypokalemia can result in cardiac arrhythmias and muscle weakness. Choices B, C, and D are incorrect because furosemide does not typically cause hyperkalemia, hypernatremia, or hypoglycemia.
4. A nurse is collecting data from a client who has a newly applied cast to the right lower extremity. Which of the following findings should the nurse expect?
- A. Capillary refill of 1 second
- B. Capillary refill of 5 seconds
- C. Pitting edema
- D. Shortness of breath
Correct answer: B
Rationale: When assessing a client with a newly applied cast, the nurse should expect a capillary refill of approximately 2 seconds, as this indicates adequate circulation. A capillary refill longer than 3 seconds suggests impaired circulation, which is abnormal. Therefore, a capillary refill of 5 seconds is the finding the nurse should expect. Pitting edema and shortness of breath are not typically directly related to a newly applied cast and should not be expected findings in this scenario.
5. What is an important consideration when administering a blood transfusion?
- A. Ensure the blood is compatible with the recipient's blood type
- B. Warm the blood to body temperature before administration
- C. Check the blood for clots before administration
- D. Ensure the recipient eats before the transfusion
Correct answer: A
Rationale: The correct answer is to ensure the blood is compatible with the recipient's blood type. This is crucial to prevent transfusion reactions, which can be life-threatening. Choice B is incorrect because warming blood to body temperature is not a standard practice and may lead to hemolysis. Choice C is incorrect as blood products are carefully screened for clots before distribution. Choice D is incorrect because it is not necessary for the recipient to eat before a blood transfusion.
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