ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A nurse is providing teaching to a client who has chronic kidney failure and an AV fistula for hemodialysis with a new prescription for epoetin alfa. Which of the following therapeutic effects of epoetin alfa should the nurse include in the teaching?
- A. Reduces blood pressure
- B. Inhibits clotting of fistula
- C. Promotes RBC production
- D. Stimulates growth of neutrophils
Correct answer: C
Rationale: The correct answer is C: Promotes RBC production. Epoetin alfa stimulates red blood cell production, which is important for clients with chronic kidney disease who may have anemia due to decreased erythropoietin production by the kidneys. Options A, B, and D are incorrect: epoetin alfa does not directly reduce blood pressure, inhibit clotting of the fistula, or stimulate growth of neutrophils.
2. A nurse is providing teaching to a client who has a new prescription for warfarin. Which of the following statements by the client indicates a need for further teaching?
- A. I will take ibuprofen for headaches.
- B. I will use an electric razor to shave.
- C. I will avoid eating large amounts of leafy green vegetables.
- D. I will have my blood levels checked regularly.
Correct answer: A
Rationale: The correct answer is A. Ibuprofen can increase the risk of bleeding when taken with warfarin, as both medications affect clotting. The client should use alternative pain relievers like acetaminophen. Choice B is correct as using an electric razor is a safe choice to prevent cuts that could lead to bleeding. Choice C is correct as warfarin interacts with vitamin K found in leafy green vegetables. Choice D is correct as regular blood level checks are necessary to monitor the effects and adjust the warfarin dosage if needed.
3. A nurse is caring for a client who has a new prescription for an antidepressant. The client reports experiencing dry mouth. Which of the following instructions should the nurse give the client?
- A. Decrease fluid intake.
- B. Chew sugarless gum.
- C. Avoid using mouthwash.
- D. Increase intake of dairy products.
Correct answer: B
Rationale: The correct answer is to instruct the client to chew sugarless gum. Chewing sugarless gum can help alleviate dry mouth by stimulating saliva production, which is a common side effect of many antidepressants. Decreasing fluid intake (choice A) is not recommended as it can worsen dry mouth. Avoiding mouthwash (choice C) is not as effective as chewing gum in stimulating saliva. Increasing intake of dairy products (choice D) is not directly related to managing dry mouth caused by antidepressants.
4. A nurse enters a client’s room and sees smoke coming from the trash can. Which action should the nurse take first?
- A. Extinguish the fire
- B. Activate the fire alarm
- C. Evacuate the room
- D. Call the client’s family
Correct answer: C
Rationale: In a fire emergency, the priority for the nurse is to ensure safety. The correct first action is to evacuate the room, following the RACE protocol, which stands for Rescue, Alarm, Contain, and Extinguish/Evacuate. Activating the fire alarm alerts others, extinguishing the fire can escalate the situation if not done correctly, and calling the client's family is not a priority in this emergency scenario.
5. A nurse is caring for a newborn diagnosed with necrotizing enterocolitis (NEC). Which of the following interventions should the nurse expect to implement?
- A. Withhold oral feedings
- B. Measure abdominal girth
- C. Position the newborn supine
- D. Apply cold compresses to the abdomen
Correct answer: B
Rationale: Measuring abdominal girth is crucial in monitoring for signs of abdominal distension, which is a key indicator of worsening necrotizing enterocolitis (NEC). It helps in assessing the progression of the condition. Positioning the newborn supine, as in choice C, can help relieve pressure on the abdomen but does not directly monitor the condition. Applying cold compresses, as in choice D, is not recommended for NEC as it can constrict blood vessels and potentially worsen the condition. Withholding oral feedings, as in choice A, is also important to rest the bowel and prevent further complications, but measuring abdominal girth is more directly related to monitoring the progression of NEC.
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