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. During a change-of-shift assessment, a nurse is evaluating four clients. Which finding should the nurse report to the provider first?
- A. A client with cystic fibrosis who has a productive cough and reports thirst
- B. A client with gastroenteritis who is lethargic and confused
- C. A client with diabetes mellitus whose blood glucose is 185 mg/dL
- D. A client with sickle cell anemia who reports pain 15 minutes after receiving analgesics
Correct answer: B
Rationale: Lethargy and confusion in a client with gastroenteritis are concerning findings that may indicate severe dehydration or electrolyte imbalance, requiring immediate intervention. While the other options are important, they do not pose an immediate life-threatening risk compared to the altered mental status in a client with gastroenteritis.
3. A healthcare professional is assessing a client for signs of hyperglycemia. Which of the following findings should the healthcare professional look for?
- A. Increased thirst
- B. Weight gain
- C. Decreased urination
- D. Fatigue
Correct answer: A
Rationale: Increased thirst is a classic symptom of hyperglycemia due to the body trying to eliminate excess glucose through urine, leading to dehydration and increased thirst. Weight gain, decreased urination, and fatigue are not typical signs of hyperglycemia. Weight gain is more commonly associated with conditions like hypothyroidism or fluid retention. Decreased urination is not a typical symptom of hyperglycemia, as high blood sugar levels usually lead to increased urination. Fatigue can be a symptom of hyperglycemia, but it is not as specific or characteristic as increased thirst.
4. A healthcare professional is assessing a client for signs of anaphylaxis. Which of the following findings should the healthcare professional look for?
- A. Bradycardia
- B. Hypotension
- C. Increased appetite
- D. Decreased respiratory rate
Correct answer: B
Rationale: Hypotension is a critical sign of anaphylaxis. During anaphylaxis, there is a widespread vasodilation leading to a drop in blood pressure, which manifests as hypotension. This can be accompanied by other symptoms such as swelling, difficulty breathing, hives, and itching. Bradycardia (choice A) is not typically associated with anaphylaxis; instead, tachycardia is more common due to the body's response to the allergic reaction. Increased appetite (choice C) is unrelated to anaphylaxis, as individuals experiencing anaphylaxis often feel unwell and may have nausea or vomiting. Decreased respiratory rate (choice D) is also not a typical finding in anaphylaxis; instead, respiratory distress and wheezing are more commonly observed.
5. A nurse is assessing a client who has a blood glucose level of 250 mg/dL. Which of the following clinical manifestations is associated with this finding?
- A. Confusion
- B. Thirst
- C. Diaphoresis
- D. Shakiness
Correct answer: B
Rationale: Corrected Detailed Rationale: A blood glucose level of 250 mg/dL indicates hyperglycemia. Thirst (polydipsia) is a common clinical manifestation associated with hyperglycemia. The body tries to compensate for the high blood sugar by increasing fluid intake. Confusion (choice A) is more commonly associated with hypoglycemia, not hyperglycemia. Diaphoresis (choice C) and shakiness (choice D) are typical manifestations of hypoglycemia, not hyperglycemia. Therefore, the correct answer is increased thirst (polydipsia) in response to the elevated blood glucose level.
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