ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is reviewing a laboratory report for a client who is at 33 weeks of gestation and has preeclampsia. Which of the following laboratory results should the nurse report to the provider?
- A. BUN 35 mg/dL
- B. Hgb 15 g/dL
- C. Bilirubin 0.6 mg/dL
- D. Hct 37%
Correct answer: A
Rationale: A BUN of 35 mg/dL indicates potential kidney impairment, which is a concern in preeclampsia due to compromised renal function. This finding warrants further evaluation by the provider. High BUN levels may suggest reduced kidney function, a common complication associated with preeclampsia. Hgb, Bilirubin, and Hct levels are within normal ranges and are not directly indicative of kidney impairment or preeclampsia in this scenario. Therefore, the nurse should report the elevated BUN level to the healthcare provider for prompt management and monitoring.
2. A healthcare professional is preparing to administer a dose of sertraline. Which of the following should the healthcare professional assess first?
- A. Blood pressure
- B. Heart rate
- C. Respiratory rate
- D. Mood changes
Correct answer: A
Rationale: When administering sertraline, assessing blood pressure is crucial as this medication can potentially affect blood pressure levels. Monitoring blood pressure before giving sertraline helps ensure patient safety and allows for appropriate interventions if any significant changes are noted. Heart rate, respiratory rate, and mood changes are important assessments but are not typically the first priority when administering sertraline. While heart rate and respiratory rate can also be affected by sertraline, blood pressure assessment is a higher priority due to the medication's known effects on blood pressure regulation.
3. While caring for a client receiving nitroglycerin for chest pain, which of the following side effects should the nurse monitor for?
- A. Hypotension
- B. Tachycardia
- C. Bradycardia
- D. Hyperglycemia
Correct answer: A
Rationale: Corrected Rationale: Nitroglycerin is known to cause hypotension due to its vasodilating effect, which can lead to low blood pressure. Therefore, the nurse should closely monitor the client for signs of hypotension such as dizziness, light-headedness, or weakness. Tachycardia (increased heart rate), bradycardia (decreased heart rate), and hyperglycemia (high blood sugar) are not typically associated with nitroglycerin use and are less likely to be side effects that the nurse needs to monitor for in this scenario.
4. A nurse in a mental health facility receives a change-of-shift report on four clients. Which of the following clients should the nurse assess first?
- A. Client placed in restraints for aggressive behavior
- B. A new client with a history of a 4.5 kg weight loss in the past two months
- C. Client who received a PRN dose of haloperidol 2 hours ago for increased anxiety
- D. Client who will be receiving his first ECT treatment today
Correct answer: A
Rationale: A client in restraints due to aggressive behavior needs immediate assessment to ensure safety and well-being. The nurse should assess this client first to address any potential risks, such as circulation issues, skin integrity problems, and ongoing agitation. Choices B, C, and D do not present immediate safety concerns that require urgent assessment compared to a client restrained for aggressive behavior.
5. Which of the following are contraindications to salicylic acid therapy?
- A. Third trimester of pregnancy
- B. Thrombocytopenia
- C. Coronary artery disease
- D. Adolescents with chickenpox
Correct answer: A
Rationale: The correct answer is A: Third trimester of pregnancy. Salicylic acid is contraindicated during the third trimester of pregnancy due to the risk of complications for both the mother and the fetus. Thrombocytopenia (choice B) is not a contraindication to salicylic acid therapy. Coronary artery disease (choice C) is not a specific contraindication to salicylic acid therapy. However, caution should be exercised in patients with coronary artery disease due to the antiplatelet effects of salicylic acid. Adolescents with chickenpox (choice D) should not be given salicylic acid due to the risk of Reye Syndrome, a rare but serious illness.
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