ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. While receiving a change of shift report on a group of clients, which patient should the nurse assess first?
- A. The client who has a fractured femur and reports sharp chest pain.
- B. The client who has a fever and is receiving antibiotics.
- C. The client who has a urinary tract infection and reports pain with urination.
- D. The client who is scheduled for surgery in the afternoon.
Correct answer: A
Rationale: The nurse should assess the client with a fractured femur and sharp chest pain first. Sharp chest pain in this client may indicate a pulmonary embolism, a life-threatening condition requiring immediate attention. The other options describe important patient conditions but do not pose an immediate threat to life like a potential pulmonary embolism does.
2. A client who was incarcerated for theft is addressing the group in a County Jail health clinic. Which of the following is an example of reaction formation?
- A. I steal things because it’s the only way I can keep my mind off my bad marriage
- B. I can’t believe I was accused of something I didn’t do
- C. I don’t want to talk about my feelings right now; we will talk more next time
- D. I think that people should earn money honestly, even though I stole
Correct answer: D
Rationale: The correct answer is D because reaction formation occurs when a person expresses the opposite of what they feel. In this case, the client is advocating for honesty, despite their own history of theft. Choice A discusses stealing to distract from a bad marriage, which does not involve expressing the opposite of one's feelings. Choice B focuses on denial, not reaction formation. Choice C involves delaying emotional discussion, which is not related to expressing the opposite of one's true feelings.
3. A nurse is planning care for a client with a sealed radiation implant. Which intervention should the nurse implement?
- A. Remove dirty linens after double-bagging them
- B. Wear a dosimeter badge in the client’s room
- C. Limit visitors to 1 hour per day
- D. Ensure family remains 3 feet away from the client
Correct answer: B
Rationale: The nurse should wear a dosimeter badge to monitor radiation exposure when caring for a client with a sealed radiation implant.
4. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following assessment findings requires immediate intervention by the nurse?
- A. Prealbumin level of 20 mg/dL
- B. Weight increase of 2 kg/day
- C. Temperature of 37.6°C
- D. Blood glucose level of 120 mg/dL
Correct answer: B
Rationale: A rapid weight gain of 2 kg/day suggests fluid overload, a possible complication of TPN. This requires immediate intervention to prevent further complications such as pulmonary edema. The other options are not indicative of immediate complications related to TPN. A low prealbumin level may indicate malnutrition but does not require immediate intervention. A slightly elevated temperature and blood glucose level are within normal ranges and do not warrant immediate action.
5. During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
- A. An irregularly shaped, nontender lump palpable in the right breast
- B. Tenderness present during menstruation
- C. Bilateral, symmetrical lumps that move with palpation
- D. The client reports breast tenderness before menstruation
Correct answer: A
Rationale: An irregularly shaped, nontender lump is a concerning finding as it may indicate breast cancer. The nurse should report this finding to the provider for further investigation. Choices B, C, and D are less concerning findings. Tenderness during menstruation is a common finding due to hormonal changes. Bilateral, symmetrical lumps that move with palpation are often benign findings like fibrocystic changes. Breast tenderness before menstruation is also a common occurrence related to hormonal fluctuations.
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