ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is reviewing a prescription for doxazosin with a client. Which instruction should the nurse include?
- A. Decrease caloric intake to reduce weight gain
- B. Increase dietary fiber to prevent constipation
- C. Rise slowly when sitting up
- D. Take this medication each morning
Correct answer: C
Rationale: The correct answer is C: 'Rise slowly when sitting up.' Doxazosin can cause orthostatic hypotension, a sudden drop in blood pressure when standing up, leading to dizziness or fainting. Instructing the client to rise slowly helps prevent this adverse effect. Choices A, B, and D are incorrect. A decrease in caloric intake to reduce weight gain, an increase in dietary fiber to prevent constipation, and taking the medication each morning are not specific instructions related to managing the side effects of doxazosin.
2. A nurse is caring for a client prescribed hydromorphone for severe pain. The client's respiratory rate has decreased from 16 breaths per minute to 6. Which of the following medications should the nurse prepare to administer?
- A. Naloxone
- B. Flumazenil
- C. Activated charcoal
- D. Aluminum hydroxide
Correct answer: A
Rationale: Naloxone is the correct answer. Naloxone is the antidote for opioid overdose, including hydromorphone. Opioids can cause respiratory depression, and a significant decrease in respiratory rate from 16 to 6 breaths per minute indicates respiratory compromise. Naloxone should be administered promptly to reverse the effects of the opioid and restore normal respiratory function. Flumazenil (Choice B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (Choice C) is used for gastrointestinal decontamination in cases of overdose with certain substances, but it is not the appropriate intervention for opioid-induced respiratory depression. Aluminum hydroxide (Choice D) is an antacid and has no role in managing opioid overdose or respiratory depression.
3. A nurse is caring for an older adult client with delirium. Which intervention will most effectively reduce the client's risk for falls?
- A. Using a night-light
- B. Demonstrating how to use the call light
- C. Placing the bedside table in close proximity
- D. Hourly rounding by the nurse
Correct answer: D
Rationale: Hourly rounding by the nurse is the most effective intervention to reduce the risk of falls in older adult clients with delirium. This intervention ensures that the nurse regularly checks on the client, assesses their needs, and assists them with any activities, thereby minimizing the chances of falls. Using a night-light (choice A) may help improve visibility but does not provide continuous assistance and monitoring. Demonstrating how to use the call light (choice B) is important but may not prevent falls directly. Placing the bedside table in close proximity (choice C) is helpful for convenience but does not address the continuous monitoring and assistance needed to prevent falls in this case.
4. A nurse is assisting with mass casualty triage following an explosion at a local factory. Which of the following clients should the nurse identify as the priority?
- A. A client who has massive head trauma
- B. A client who has full-thickness burns to the face and trunk
- C. A client with indications of hypovolemic shock
- D. A client with an open fracture of the lower extremity
Correct answer: C
Rationale: In a mass casualty situation, the nurse should prioritize the client with indications of hypovolemic shock. Hypovolemic shock is an immediate life-threatening condition resulting from severe blood loss, which can lead to organ failure and death. Prompt identification and treatment of hypovolemic shock are crucial to prevent further deterioration. While clients with massive head trauma, full-thickness burns, and open fractures require urgent care, hypovolemic shock takes precedence due to its rapid progression to a critical state.
5. A client with a history of asthma is being cared for by a nurse. Which of the following should the nurse monitor?
- A. Heart rate
- B. Respiratory status
- C. Blood glucose levels
- D. Liver function
Correct answer: B
Rationale: The correct answer is B: Respiratory status. When caring for a client with asthma, it is essential to monitor their respiratory status to detect any changes in breathing or signs of airway obstruction. Monitoring heart rate (choice A) may be important in some situations but is not the priority when managing asthma. Blood glucose levels (choice C) and liver function (choice D) are not directly related to asthma and would not be the primary focus of monitoring for a client with this condition.
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