ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is providing teaching for a client who is prescribed enoxaparin for DVT prevention. What is an appropriate action by the nurse?
- A. Expel the air bubble from the prefilled syringe
- B. Massage the injection site to distribute the medication
- C. Inject the medication into the lateral abdominal wall
- D. Administer an NSAID for injection site discomfort
Correct answer: C
Rationale: The correct action for a nurse when administering enoxaparin for DVT prevention is to inject the medication into the lateral abdominal wall. This is the recommended site for enoxaparin administration. Expelling the air bubble is unnecessary and may lead to a dosage error. Massaging the injection site is not recommended as it can cause bruising. Administering an NSAID for injection site discomfort is not necessary as discomfort should be minimal and transient.
2. The nurse is assisting in the care of a client with a history of chronic obstructive pulmonary disease (COPD) who is on oxygen therapy. Which action should the nurse take to ensure the client's safety?
- A. Set the oxygen flow rate to 4 liters per minute.
- B. Remove oxygen while the client is eating.
- C. Ensure the client wears a nasal cannula instead of a face mask.
- D. Maintain the oxygen flow rate at the lowest level that relieves hypoxia.
Correct answer: D
Rationale: For clients with COPD, too much oxygen can suppress their drive to breathe, leading to hypoventilation. Therefore, the nurse should maintain the oxygen flow rate at the lowest level that relieves hypoxia to prevent complications while ensuring adequate oxygenation. Setting the oxygen flow rate too high (Choice A) can be detrimental for the client with COPD. Removing oxygen while the client is eating (Choice B) can compromise oxygenation, which is essential even during meals. While nasal cannulas are commonly used, the choice of oxygen delivery device depends on the client's needs; there may be situations where a face mask (Choice C) is more appropriate.
3. A client has a new prescription for atenolol. Which of the following instructions should be included in the discharge teaching?
- A. Take the medication at bedtime.
- B. Monitor your heart rate daily.
- C. Increase your intake of potassium-rich foods.
- D. Avoid consuming dairy products.
Correct answer: B
Rationale: The correct answer is to instruct the client to monitor their heart rate daily when taking atenolol. Atenolol can lead to bradycardia, a slow heart rate. By monitoring heart rate daily, the client can promptly identify any significant changes and seek medical attention if necessary. This proactive approach enables early detection of potential adverse effects of atenolol, contributing to the client's safety and well-being. Choices A, C, and D are incorrect because taking atenolol at bedtime, increasing potassium-rich foods intake, or avoiding dairy products are not specific instructions related to the potential side effects of atenolol.
4. Which statement is true of primary facilities?
- A. They are usually government-run.
- B. Their services are provided on an outpatient basis.
- C. They are training facilities for health professionals.
- D. A community hospital is an example of this level of health facility.
Correct answer: B
Rationale: Primary facilities are typically healthcare facilities that offer basic outpatient services to individuals. These services are often provided without the need for an overnight stay, distinguishing them from secondary or tertiary care facilities that offer more specialized and intensive care. Therefore, the correct statement about primary facilities is that their services are provided on an outpatient basis.
5. Which intervention should be included for a client with heart failure?
- A. Encourage increased fluid intake
- B. Weigh the client daily to monitor fluid balance
- C. Restrict fluid intake during meals
- D. Limit daily activity to prevent fatigue
Correct answer: B
Rationale: Weighing the client daily to monitor fluid balance is crucial for clients with heart failure. This intervention helps assess for fluid retention or depletion, providing valuable information for managing the condition effectively. Encouraging increased fluid intake (Choice A) is contraindicated in heart failure as it can worsen fluid overload. Restricting fluid intake during meals (Choice C) may lead to dehydration, which is harmful for clients with heart failure. Limiting daily activity (Choice D) is not recommended as appropriate activity levels should be encouraged for overall well-being, under guidance to prevent excessive fatigue.
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