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 nurse is caring for a newborn immediately following birth. What should the nurse do first?
- A. Instill erythromycin ophthalmic ointment
- B. Place identification bracelets on the newborn
- C. Weigh the newborn
- D. Dry the newborn
Correct answer: D
Rationale: Drying the newborn is the first priority to prevent heat loss, which can occur rapidly in newborns due to their large surface area and lack of body fat. This helps maintain the newborn's body temperature and prevent hypothermia. Instilling erythromycin ophthalmic ointment, placing identification bracelets, and weighing the newborn can be important steps but should come after ensuring the newborn is dried to maintain their body temperature.
3. A healthcare professional is assessing a client for potential complications after surgery. Which of the following should the healthcare professional monitor for?
- A. Decreased urine output
- B. Increased appetite
- C. Improved mobility
- D. Normal temperature
Correct answer: A
Rationale: Corrected Rationale: Decreased urine output can indicate renal complications or dehydration, which are common post-surgical complications. Monitoring urine output is crucial for detecting early signs of kidney dysfunction or fluid imbalances. Increased appetite, improved mobility, and normal temperature are not typical signs of immediate post-surgical complications and would not be the priority for monitoring in this case.
4. A nurse is caring for a newborn diagnosed with necrotizing enterocolitis (NEC). Which of the following interventions should the nurse expect to implement?
- A. Withhold oral feedings
- B. Measure abdominal girth
- C. Position the newborn supine
- D. Apply cold compresses to the abdomen
Correct answer: B
Rationale: Measuring abdominal girth is crucial in monitoring for signs of abdominal distension, which is a key indicator of worsening necrotizing enterocolitis (NEC). It helps in assessing the progression of the condition. Positioning the newborn supine, as in choice C, can help relieve pressure on the abdomen but does not directly monitor the condition. Applying cold compresses, as in choice D, is not recommended for NEC as it can constrict blood vessels and potentially worsen the condition. Withholding oral feedings, as in choice A, is also important to rest the bowel and prevent further complications, but measuring abdominal girth is more directly related to monitoring the progression of NEC.
5. A client is receiving oxytocin to augment labor. The contractions are occurring every 45 seconds, and the fetal heart rate is 170-180 beats/min. What action should the nurse take?
- A. Increase the oxytocin infusion
- B. Decrease the oxytocin infusion
- C. Discontinue the oxytocin infusion
- D. Maintain the oxytocin infusion
Correct answer: C
Rationale: When contractions occur every 45 seconds with a high fetal heart rate, it indicates uterine hyperstimulation and fetal distress. In this situation, the oxytocin infusion should be discontinued immediately to prevent further complications. Increasing or maintaining the infusion would worsen the hyperstimulation and distress. Decreasing the infusion may not be sufficient to address the current situation and could still lead to complications.
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