ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A nurse is reviewing the laboratory values for a client who is receiving a continuous IV heparin infusion and has an aPTT of 90 seconds. Which of the following actions should the nurse prepare to take?
- A. Administer vitamin K
- B. Reduce the infusion rate
- C. Give the client a low-dose aspirin
- D. Request an INR
Correct answer: B
Rationale: An aPTT of 90 seconds is elevated, indicating a risk of bleeding due to excessive anticoagulation. The appropriate action is to reduce the infusion rate of heparin to prevent further complications. Administering vitamin K is not indicated for an elevated aPTT due to heparin therapy. Giving the client a low-dose aspirin can further increase the risk of bleeding when combined with heparin. Requesting an INR is not necessary for monitoring heparin therapy; aPTT is the more specific test for assessing heparin's therapeutic effect. Therefore, the correct action for the nurse to prepare to take is to reduce the infusion rate of heparin.
2. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?
- A. Change the appliance daily
- B. Clean the stoma once a day
- C. Avoid changing the appliance for a week
- D. Change the appliance twice each week
Correct answer: D
Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.
3. Which of the following is a benefit of providing Vitamin A supplements to children?
- A. Improves cognitive development
- B. Reduces the risk of severe measles
- C. Prevents iron deficiency anemia
- D. Enhances physical growth
Correct answer: B
Rationale: The correct benefit of providing Vitamin A supplements to children is reducing the risk of severe measles. Vitamin A supplementation is known to lower the risk of severe measles and its associated complications, making it an important intervention in regions where measles is prevalent.
4. A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?
- A. Tachycardia
- B. Hypotension
- C. Increased urine output
- D. Diarrhea
Correct answer: C
Rationale: Increased urine output is a positive sign that the IV fluids are effectively treating dehydration. Tachycardia (choice A) and hypotension (choice B) are signs of dehydration and would not be considered positive responses to therapy. Diarrhea (choice D) can worsen dehydration and is not a positive response to IV fluid therapy.
5. Tomas is a 21-year-old male with a recent diagnosis of schizophrenia. Tomas’s nurse recognizes that self-medicating with excessive alcohol is common in this disease and can co-occur along with:
- A. Generally good health despite the mental illness.
- B. An aversion to drinking fluids.
- C. Anxiety and depression.
- D. The ability to express his needs.
Correct answer: C
Rationale: Individuals with schizophrenia often turn to alcohol as a form of self-medication to manage co-occurring symptoms of anxiety and depression. This coping mechanism can exacerbate the underlying mental health condition and hinder proper treatment. Recognizing and addressing these co-occurring issues are essential in providing holistic care for individuals with schizophrenia.