ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A healthcare professional is reviewing the health history of an older adult who has a hip fracture. What is a risk factor for developing pressure injuries?
- A. Dehydration
- B. Urinary incontinence
- C. Poor nutrition
- D. Poor tissue perfusion
Correct answer: B
Rationale: Urinary incontinence is a risk factor for developing pressure injuries due to prolonged skin exposure to moisture and irritants. Dehydration (choice A) can contribute to skin dryness but is not a direct risk factor for pressure injuries. Poor nutrition (choice C) can affect wound healing but is not specifically linked to pressure injuries. Poor tissue perfusion (choice D) can increase the risk of tissue damage but is not as directly associated with pressure injuries as urinary incontinence.
2. A nurse is caring for a client with a prescription for ferrous sulfate. What instruction should the nurse provide?
- A. Avoid strawberries and citrus fruits
- B. Take with fluids other than coffee or tea
- C. Take on a full stomach
- D. Double the dose if you miss a dose
Correct answer: B
Rationale: The correct instruction for a client prescribed ferrous sulfate is to take it with fluids other than coffee or tea. Coffee and tea can hinder iron absorption, so it's important to take the medication with other types of fluids. Choice A is incorrect because strawberries and citrus fruits are sources of vitamin C, which actually enhance iron absorption. Choice C is incorrect because ferrous sulfate is usually recommended to be taken on an empty stomach for better absorption. Choice D is incorrect as doubling the dose of ferrous sulfate can lead to an overdose and severe side effects.
3. A nurse is developing discharge care plans for a client who has osteoporosis. To prevent injury, the nurse should instruct the client to:
- A. Perform weight-bearing exercises
- B. Avoid crossing the legs beyond the midline
- C. Avoid sitting in one position for prolonged periods
- D. Splint the affected area
Correct answer: A
Rationale: The correct answer is A: Perform weight-bearing exercises. Weight-bearing exercises strengthen bones and help prevent fractures, which is crucial for clients with osteoporosis. Choices B, C, and D are incorrect. Avoiding crossing the legs beyond the midline and avoiding sitting in one position for prolonged periods are general recommendations for preventing musculoskeletal issues but are not specific to osteoporosis. Splinting the affected area is not a standard practice for managing osteoporosis and preventing fractures.
4. A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?
- A. Limit the client’s fluid intake to 1500 mL per day
- B. Massage the affected extremity to relieve pain
- C. Apply cold packs to the affected extremity
- D. Elevate the client’s affected extremity when in bed
Correct answer: D
Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.
5. A charge nurse is preparing an educational session about addictive disorders for nursing staff. Which of the following should the nurse include as an etiological factor of addictive disorder?
- A. Low self-esteem
- B. Family history of addiction
- C. Personality disorders
- D. All of the above
Correct answer: D
Rationale: The correct answer is D: All of the above. Addiction is influenced by various factors, including low self-esteem, family history of addiction, and specific personality traits. Low self-esteem can lead individuals to seek solace in substances, a family history of addiction can increase the likelihood of developing addictive behaviors due to genetic and environmental factors, and certain personality disorders may contribute to addictive tendencies. Therefore, all the factors listed in choices A, B, and C can play a role in the development of addictive disorders. Choices A, B, and C are incorrect because addictive disorders are multifactorial, and it is essential to consider a combination of influences rather than isolating a single factor.
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