ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A nurse is reviewing information about advance directives with a newly admitted client. Which statement by the client indicates an understanding of the teaching?
- A. My family can make decisions if I am unable to.
- B. I have a living will that outlines my wishes when I am unable to make a decision.
- C. I can write down my wishes, but they aren't legally binding.
- D. I don't need to worry about this until I’m critically ill.
Correct answer: B
Rationale: Choice B is the correct answer because having a living will is a legal document that outlines a client's wishes when they are unable to make decisions, indicating a good understanding of advance directives. Choice A is incorrect because it doesn't mention a specific document like a living will. Choice C is incorrect because advance directives, like a living will, can be legally binding. Choice D is incorrect because planning for advance directives should ideally be done before a person becomes critically ill.
2. A nurse is caring for a group of patients. Which of the following clients should the nurse refer to a social worker?
- A. A patient who requests to secure an emergency notification system in the home.
- B. A client who requires placement in an assisted living facility.
- C. A patient who requests to get school assignments while hospitalized on a pediatric unit.
- D. A patient who is experiencing food insecurity.
Correct answer: B
Rationale: The correct answer is B because social workers are involved in arranging care services like placement in assisted living facilities. This client's need for placement in an assisted living facility requires the expertise and assistance of a social worker. Choices A, C, and D do not necessarily require the intervention of a social worker. Choice A can be addressed by a nurse or healthcare provider, choice C can be managed by hospital staff or educators, and choice D may involve a nutritionist or community outreach programs.
3. A nurse is planning care for a patient who follows the Mormon belief system. What modifications should the nurse include to meet Mormon dietary practices?
- A. Offer only vegetarian meal options.
- B. Offer non-caffeinated beverage options.
- C. Offer kosher meals.
- D. Limit meat to only fish and poultry.
Correct answer: B
Rationale: The correct answer is B: Offer non-caffeinated beverage options. Mormons avoid caffeinated beverages, so providing non-caffeinated options aligns with their religious practices. Choice A is incorrect because offering only vegetarian meal options is not a specific requirement of the Mormon dietary practices. Choice C is incorrect as kosher meals are associated with Jewish dietary laws, not specific to the Mormon belief system. Choice D is incorrect as limiting meat to only fish and poultry is not a specific dietary requirement for Mormons.
4. A postpartum client with AB negative blood whose newborn is B positive requires what intervention?
- A. Administer Rh immune globulin within 72 hours of delivery
- B. Administer Rh immune globulin at the 6-week postpartum visit
- C. No Rh immune globulin is needed since this is the second pregnancy
- D. Both mother and baby need Rh immune globulin
Correct answer: A
Rationale: The correct intervention is to administer Rh immune globulin within 72 hours of delivery. This is essential to prevent the mother from forming antibodies against Rh-positive blood, which could cause complications in future pregnancies. Choice B is incorrect as the administration should be immediate postpartum. Choice C is incorrect as Rh immune globulin is needed for each Rh-incompatible pregnancy. Choice D is incorrect as only the mother, who is Rh-negative, needs Rh immune globulin.
5. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?
- A. Position the client with the affected extremity lower than the heart
- B. Administer acetaminophen for pain
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct answer: D
Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.
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