ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is providing discharge teaching to a client with a new prescription for furosemide. Which client statement indicates a need for further teaching?
- A. I will take my morning pills with food or milk.
- B. I will weigh myself every day.
- C. I will notify the nurse if I have muscle cramps.
- D. I will limit my intake of fish.
Correct answer: D
Rationale: The correct answer is D. Furosemide is a diuretic that does not require a reduction in fish consumption. Therefore, the statement 'I will limit my intake of fish' indicates a misunderstanding of dietary considerations. Choices A, B, and C are all appropriate actions related to furosemide therapy. Taking pills with food or milk can help reduce stomach upset, daily weight monitoring is crucial due to the diuretic effect of furosemide, and notifying the nurse about muscle cramps is important as it can be a sign of electrolyte imbalance, a potential side effect of furosemide.
2. A client who is 28 weeks pregnant and has preeclampsia is being cared for by a nurse. Which of the following is the priority assessment?
- A. Level of consciousness
- B. Deep tendon reflexes
- C. Blood pressure
- D. Urinary output
Correct answer: C
Rationale: Blood pressure is the priority assessment in clients with preeclampsia because hypertension is the primary symptom of the condition. Elevated blood pressure increases the risk of complications such as eclampsia and placental abruption. Assessing the blood pressure helps in monitoring the severity of the preeclampsia and guiding appropriate interventions. While monitoring the client's level of consciousness, deep tendon reflexes, and urinary output are important, they are secondary assessments in the context of preeclampsia.
3. A client with hepatic encephalopathy is being educated about their diet by a nurse. Which of the following food selections indicates that the client understands the teaching?
- A. A sandwich and a milkshake
- B. Rice with black beans
- C. Cottage cheese and tuna on lettuce
- D. A three-egg omelet with low-sodium ham
Correct answer: B
Rationale: The correct answer is B: Rice with black beans. Clients with hepatic encephalopathy should limit protein intake to prevent the buildup of ammonia. Plant-based proteins are preferred over animal-based proteins in this condition. Rice with black beans provides a good balance of nutrients and is a suitable choice for a client with hepatic encephalopathy. Choices A, C, and D are incorrect because they contain animal-based proteins, which should be limited in clients with hepatic encephalopathy.
4. A client with a history of urinary tract infections (UTIs) is being cared for by a nurse. Which of the following instructions should the nurse provide to prevent future infections?
- A. Wipe from front to back after urination
- B. Drink 2-3 liters of water per day
- C. Avoid holding urine for long periods
- D. Wear loose-fitting underwear
Correct answer: B
Rationale: The correct answer is to advise the client to drink 2-3 liters of water per day. Adequate hydration helps flush bacteria from the urinary tract, reducing the risk of UTIs. Choice A is incorrect because wiping from front to back is the appropriate technique to prevent the spread of bacteria from the rectal area to the urethra. Choice C is incorrect as holding urine for long periods can contribute to UTIs by allowing bacteria to grow in the bladder. Choice D is incorrect as wearing loose-fitting underwear is recommended to allow air circulation and prevent moisture buildup, reducing the risk of UTIs.
5. During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?
- A. Client with cystic fibrosis who has a thick productive cough and reports thirst
- B. Client with gastroenteritis who is lethargic and confused
- C. Client with diabetes mellitus who has a morning fasting glucose of 185 mg/dL
- D. Client with sickle cell anemia who reports pain 15 minutes after receiving analgesic
Correct answer: B
Rationale: The nurse should report the client with gastroenteritis who is lethargic and confused to the provider first. Lethargy and confusion in a client with gastroenteritis may indicate dehydration or electrolyte imbalance, both of which can be life-threatening if not addressed promptly. The other options indicate important assessments that require intervention but do not pose an immediate life-threatening risk compared to the client with signs of dehydration and electrolyte imbalance.
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