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 nurse is preparing to administer a dose of losartan. Which of the following should the nurse assess first?
- A. Blood pressure
- B. Heart rate
- C. Serum potassium
- D. Liver function
Correct answer: A
Rationale: The correct answer is to assess blood pressure first. Losartan is an angiotensin receptor blocker used to lower blood pressure. Assessing the patient's blood pressure before administering losartan is crucial to ensure it is not already too low, which could lead to hypotension. Assessing heart rate (choice B) is important but not the priority when administering losartan. Serum potassium levels (choice C) and liver function (choice D) are also important assessments, but they are not the primary concern before administering losartan.
3. A healthcare professional is assessing a client with heart failure. Which of the following signs should the healthcare professional monitor for?
- A. Peripheral edema
- B. Tachycardia
- C. Bradycardia
- D. Hypotension
Correct answer: A
Rationale: In heart failure, the accumulation of fluid can lead to peripheral edema, which is swelling in the extremities. This is a common sign that healthcare professionals should monitor for. While tachycardia (increased heart rate), bradycardia (decreased heart rate), and hypotension (low blood pressure) can also occur in heart failure, they are not the primary signs typically associated with this condition. Therefore, peripheral edema is the most relevant sign to monitor in this case.
4. A client expresses anxiety about an upcoming surgery. What should the nurse do?
- A. Reassure the client that everything will be fine
- B. Ask the client to describe feelings
- C. Tell the client to stay positive
- D. Provide information about the surgery
Correct answer: B
Rationale: Asking the client to describe their feelings is the most appropriate action for the nurse to take. This allows the nurse to understand the specific concerns and anxieties the client is experiencing. Choice A may invalidate the client's feelings and not address the root cause of anxiety. Choice C may come across as dismissive and oversimplified. While providing information about the surgery (Choice D) is important, addressing the client's emotional state is the initial priority in this situation.
5. A nurse is assessing a client who has a sodium level of 122 mEq/L. Which of the following findings should the nurse expect?
- A. Decreased deep tendon reflexes
- B. Positive Trousseau’s sign
- C. Hypoactive bowel sounds
- D. Sticky mucous membranes
Correct answer: A
Rationale: A sodium level of 122 mEq/L indicates hyponatremia, which is characterized by decreased deep tendon reflexes. Hyponatremia leads to neurological symptoms such as altered reflexes. Choices B, C, and D are not typically associated with hyponatremia. Positive Trousseau’s sign is related to hypocalcemia, hypoactive bowel sounds can be seen in paralytic ileus or decreased peristalsis, and sticky mucous membranes are not specific findings related to sodium imbalances.
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