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. A nurse is providing discharge teaching to a client who has a prescription for home oxygen. Which information should the nurse teach?
- A. Use a humidifier with the oxygen
- B. Wear cotton socks when the oxygen is in use
- C. Avoid all types of smoking materials
- D. Use a nasal cannula during meals
Correct answer: B
Rationale: The correct answer is B: 'Wear cotton socks when the oxygen is in use.' This information is important as wearing cotton socks helps prevent static electricity, which can pose a fire risk when oxygen is in use. Choice A is incorrect as using a humidifier with oxygen is not necessary for all clients and may not be part of standard discharge teaching. Choice C is incorrect as it is a common safety measure to avoid all types of smoking materials when using oxygen. Choice D is incorrect as using a nasal cannula during meals is not specifically related to the safety concerns associated with home oxygen use.
3. A client has been prescribed nitroglycerin for chest pain. Which of the following should the nurse include in the teaching?
- A. Take one tablet every hour for chest pain.
- B. Store nitroglycerin tablets in a cool, dark place.
- C. Take nitroglycerin with food to reduce stomach upset.
- D. Take nitroglycerin with an antacid to prevent heartburn.
Correct answer: B
Rationale: The correct answer is B. Nitroglycerin tablets should be stored in a cool, dark place to maintain their potency. Storing them correctly ensures that they remain effective when needed. Choices A, C, and D are incorrect. Taking one tablet every hour is not the correct dosing regimen for nitroglycerin. Nitroglycerin is usually taken as needed at the onset of chest pain, with specific instructions from the healthcare provider. Taking nitroglycerin with food or antacids is not necessary, as it is usually placed under the tongue for rapid absorption.
4. A client has been prescribed ferrous sulfate. Which instruction should the nurse include?
- A. Take with meals
- B. Take with a glass of orange juice
- C. Take at bedtime
- D. Take with milk
Correct answer: B
Rationale: The correct instruction for a client prescribed ferrous sulfate is to take it with a glass of orange juice. Vitamin C, found in orange juice, enhances the absorption of iron, making it more effective. Taking ferrous sulfate with meals, at bedtime, or with milk can decrease its absorption and effectiveness, so these options are incorrect.
5. A home health nurse is providing teaching to the family of a client who has a seizure disorder. Which of the following interventions should the nurse include in the teaching?
- A. Keep a padded tongue depressor near the bedside
- B. Place a pillow under the client’s head while in bed during a seizure
- C. Administer diazepam intravenously at the onset of seizures
- D. Position the client on their side during a seizure
Correct answer: D
Rationale: Clients who have seizures are at risk for injury and aspiration. Therefore, the nurse should instruct the family to position the client on their side during a seizure to maintain a clear airway. Placing a padded tongue depressor near the bedside (Choice A) is not recommended, as it can lead to oral injury during a seizure. Placing a pillow under the client’s head (Choice B) can obstruct the airway and increase the risk of aspiration. Administering diazepam orally (Choice C) is not typically done by family members during a seizure; this is usually prescribed by healthcare providers for specific situations.
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