ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is providing teaching for a child who is prescribed ferrous sulfate. Which of the following instructions should the nurse include?
- A. Take the medication with milk
- B. Take with a glass of orange juice
- C. Take at bedtime
- D. Take with meals
Correct answer: B
Rationale: The correct answer is B: 'Take with a glass of orange juice.' Ferrous sulfate should be taken with orange juice (vitamin C) to enhance the absorption of iron. Taking it with milk (choice A) is not recommended as calcium can interfere with iron absorption. Taking it at bedtime (choice C) or with meals (choice D) may lead to decreased absorption due to interactions with other food or medications.
2. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate. Which of the following is an indication of magnesium toxicity?
- A. Blood glucose of 160 mg/dL
- B. Urine output of 20 mL/hour
- C. Systolic BP of 140 mm Hg
- D. Respiratory rate of 20/min
Correct answer: B
Rationale: The correct answer is B: Urine output of 20 mL/hour. Urine output below 30 mL/hour is a sign of magnesium toxicity due to the risk of accumulation in the body. Choices A, C, and D are not indicative of magnesium toxicity. Elevated blood glucose, systolic blood pressure, and normal respiratory rate are not specific signs of magnesium toxicity.
3. A nurse is preparing to administer a client's first dose of a new antibiotic. Which of the following is the priority nursing action?
- A. Assess the client's allergies.
- B. Monitor the client's vital signs.
- C. Inform the client of potential side effects.
- D. Obtain the client's informed consent.
Correct answer: A
Rationale: Assessing allergies before administering a new medication is crucial as it helps prevent potentially life-threatening allergic reactions like anaphylaxis. While monitoring vital signs and informing the client of side effects are important nursing actions, assessing allergies takes precedence to ensure the client's safety. Informed consent is necessary for the treatment process, but assessing allergies is the priority before administering any new medication.
4. A nurse in a clinic is caring for a patient who has a UTI. What prescription should the nurse verify with a provider?
- A. Ciprofloxacin
- B. Trimethoprim-sulfamethoxazole
- C. Oxybutynin
- D. Nitrofurantoin
Correct answer: C
Rationale: The correct answer is C: Oxybutynin. Oxybutynin is an anticholinergic used to treat overactive bladder, not a UTI. The nurse should verify this prescription because it may not be appropriate for a UTI. Choices A, B, and D are antibiotics commonly used in the treatment of UTIs. Ciprofloxacin, trimethoprim-sulfamethoxazole, and nitrofurantoin are more suitable choices for the treatment of a UTI compared to oxybutynin.
5. A nurse is caring for a client receiving radiation treatments for cancer. The client states he is experiencing dryness, redness, and scaling at the treatment area. Which of the following should the nurse instruct the client to do?
- A. Sit in the sun for 15 minutes per day.
- B. Apply moist heat to the area twice daily.
- C. Liberally apply prescribed lotion to the area.
- D. Wash the affected area daily with antimicrobial soap.
Correct answer: C
Rationale: The nurse should instruct the client to liberally apply prescribed lotion to the treatment area. Prescribed hydrating lotions help soothe and protect irradiated skin, reducing dryness, redness, and scaling. Sitting in the sun can further damage the skin. Applying moist heat may exacerbate the skin condition. Washing the area with antimicrobial soap can be too harsh and further irritate the skin.
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