ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A nurse is providing teaching to a newly licensed nurse about administering morphine via IV bolus to a client. Which of the following information should the nurse include in the teaching?
- A. Respiratory depression can occur within 7 minutes after the morphine is administered.
- B. The morphine will peak within a few minutes.
- C. Withhold the morphine if the client has a respiratory rate less than 16/min.
- D. Administer the morphine over 2 minutes.
Correct answer: A
Rationale: The correct answer is A because respiratory depression is a significant risk when administering morphine, and it can occur within 7 minutes after administration. This information is crucial for the nurse to recognize and respond promptly. Choice B is incorrect because the peak effect of morphine via IV bolus is typically reached within a few minutes, not specifically 10 minutes. Choice C is incorrect because withholding morphine based solely on a respiratory rate less than 16/min may not be appropriate without considering other factors such as pain level, oxygen saturation, and overall respiratory status. Choice D is incorrect because administering morphine over 2 minutes may not prevent respiratory depression if it occurs rapidly after administration. Nurses should be vigilant for signs of respiratory depression regardless of the administration duration.
2. A nurse is teaching a group of assistive personnel (AP) about caring for clients with Alzheimer's disease. Which of the following information should the nurse include in the teaching?
- A. Explain procedures clearly to the client before initiating care
- B. Encourage a variety of activities to engage the client
- C. Use simple and calm communication with a client who has difficulty speaking
- D. Provide supervision to prevent a client from becoming injured or lost
Correct answer: D
Rationale: The correct answer is D because clients with Alzheimer's disease can be prone to wandering and getting lost. Providing supervision can help prevent injuries and ensure their safety. Choices A, B, and C are incorrect because explaining procedures clearly, encouraging varied activities, and using simple communication are important but not specifically focused on the safety aspect of preventing clients from getting lost or injured.
3. A client has developed phlebitis at the IV site. What should the nurse do immediately?
- A. Apply a warm compress over the IV site
- B. Discontinue the IV and notify the provider
- C. Monitor the site for signs of infection
- D. Administer an anti-inflammatory medication
Correct answer: B
Rationale: When a client develops phlebitis at the IV site, the immediate action the nurse should take is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and if left untreated, it can lead to serious complications such as infection, thrombosis, or sepsis. Removing the IV line helps prevent further irritation and infection. Applying a warm compress (Choice A) may provide some relief but does not address the root cause. Monitoring for signs of infection (Choice C) is important but not the immediate action needed to address phlebitis. Administering an anti-inflammatory medication (Choice D) may be prescribed by the provider but is not the first step in managing phlebitis.
4. Which of the following statements is true about ischemic colitis?
- A. Typically requires colonic resection
- B. Affects the watershed areas of the colon, namely, the splenic flexure, right colon, and rectum
- C. Is only seen in the elderly
- D. Requires colonoscopic intervention
Correct answer: B
Rationale: Ischemic colitis most often results from low-flow states associated with hypotension or poor perfusion. As a result, the vascular watershed areas of the colon, including the splenic flexure, right colon, and rectum, are at highest risk of ischemic injury. Therefore, option B is correct as it accurately identifies the areas commonly affected by ischemic colitis.
5. A nurse is caring for a client with hepatic encephalopathy. Which food selection indicates an understanding of dietary teaching?
- A. Cottage cheese
- B. Tuna salad
- C. Rice with black beans
- D. Three-egg omelet
Correct answer: C
Rationale: The correct answer is C: 'Rice with black beans.' Clients with hepatic encephalopathy should limit animal proteins due to their high ammonia content, which can exacerbate symptoms. Plant-based proteins like beans are preferred as they help reduce ammonia levels. Choices A, B, and D contain animal proteins that are not ideal for clients with hepatic encephalopathy.