ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. When providing education on the use of insulin, what should be included?
- A. Insulin can be stored at room temperature indefinitely
- B. Monitor blood glucose levels before administration
- C. Insulin is a long-acting medication
- D. Insulin has no side effects
Correct answer: B
Rationale: The correct answer is to monitor blood glucose levels before administration. This step is crucial to ensure the correct dose of insulin is administered based on the current blood glucose level. Choice A is incorrect as insulin usually needs to be stored in the refrigerator and has an expiration date. Choice C is incorrect because insulin can be short-acting, rapid-acting, intermediate-acting, or long-acting. Choice D is also incorrect as insulin can have side effects such as hypoglycemia if the dose is too high.
2. A nurse is providing teaching to a client who has chronic kidney disease. Which of the following client statements indicates an understanding of the teaching?
- A. I will decrease my intake of foods that are high in phosphorus
- B. I will increase my intake of foods that are high in potassium
- C. I will decrease my intake of foods that are high in iron
- D. I will increase my intake of calcium supplements
Correct answer: A
Rationale: The correct answer is A. Clients with chronic kidney disease should limit their intake of phosphorus because high phosphorus levels can lead to bone disease and cardiovascular problems. Increasing foods high in potassium (choice B) is not recommended as it can be harmful to individuals with kidney disease. Decreasing intake of foods high in iron (choice C) is not specifically indicated for chronic kidney disease. Increasing calcium supplements (choice D) may not be necessary and can potentially lead to hypercalcemia in individuals with kidney disease.
3. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which of the following types of immunity?
- A. Innate immunity
- B. Passive immunity
- C. Acquired immunity
- D. Natural immunity
Correct answer: C
Rationale: Immunizations provide acquired immunity. They work by introducing antigens into the body, which triggers the immune system to produce antibodies specific to that antigen. Choice A, 'Innate immunity,' refers to the natural defense mechanisms an organism is born with and does not involve immunizations. Choice B, 'Passive immunity,' is the transfer of pre-formed antibodies and does not involve immunizations. Choice D, 'Natural immunity,' is a general term that encompasses all immunity that is not acquired through deliberate immunization or passive transfer of antibodies.
4. A nurse is assessing a client who has a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?
- A. Tidaling with spontaneous respirations
- B. Drainage collection chamber is 1/3 full
- C. 1 cm of water present in the water seal chamber
- D. Suction chamber pressure of -20 cm H2O
Correct answer: C
Rationale: The correct answer is C. There should be 2 cm of water in the water seal chamber of the chest tube system. A level of 1 cm may indicate a leak or compromised functionality that requires intervention. Choices A, B, and D are not findings that necessarily require immediate intervention. Tidaling with spontaneous respirations is an expected finding, the drainage collection chamber being 1/3 full is within normal limits, and a suction chamber pressure of -20 cm H2O indicates appropriate suction for chest drainage.
5. A client with multiple sclerosis reports diplopia. Which of the following actions should the nurse take?
- A. Encourage the client to focus on a distant object.
- B. Apply a warm compress to the client’s eyes.
- C. Recommend alternating eye patches during the day.
- D. Administer artificial tears.
Correct answer: C
Rationale: The correct action for the nurse to take when caring for a client with multiple sclerosis reporting diplopia is to recommend alternating eye patches during the day. This strategy can help relieve diplopia (double vision) by allowing each eye to rest alternately, reducing eye strain. Encouraging the client to focus on a distant object (Choice A) is not an appropriate intervention for diplopia in this case. Applying a warm compress to the client's eyes (Choice B) and administering artificial tears (Choice D) are not effective interventions for diplopia associated with multiple sclerosis.
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