ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A nurse is teaching a client about the use of nitrofurantoin. Which of the following should be included?
- A. It can cause a brown discoloration of urine
- B. It should be taken with food
- C. It has no side effects
- D. It is safe during pregnancy
Correct answer: A
Rationale: The correct answer is A. Nitrofurantoin can cause a harmless brown discoloration of urine. Choice B is also correct as it should be taken with food to enhance absorption. Choice C is incorrect as nitrofurantoin does have side effects, such as gastrointestinal disturbances. Choice D is incorrect as nitrofurantoin is not recommended during the last month of pregnancy due to potential risks to the fetus.
2. A client gave birth 4 hours ago and is experiencing excessive vaginal bleeding. Which of the following actions should the nurse plan to take first?
- A. Elevate the client's legs to a 30° angle
- B. Insert an indwelling urinary catheter
- C. Massage the client's fundus
- D. Initiate an infusion of oxytocin
Correct answer: C
Rationale: The correct answer is to massage the client's fundus first. Uterine atony is a common cause of postpartum hemorrhage, and massaging the fundus can help stimulate uterine contractions, which will assist in reducing bleeding. Elevating the client's legs to a 30° angle (Choice A) is not the priority in this situation as fundal massage takes precedence. Inserting an indwelling urinary catheter (Choice B) may be necessary but should not take precedence over managing the postpartum hemorrhage. Initiating an infusion of oxytocin (Choice D) is a valid intervention to address uterine atony, but massaging the fundus should come first to promote immediate contraction and control bleeding.
3. A healthcare professional is preparing to administer 250 mg of an antibiotic IM. Available is 3 g/5 mL. How many mL would the healthcare professional administer per dose?
- A. 0.4 mL
- B. 0.3 mL
- C. 0.5 mL
- D. 0.6 mL
Correct answer: A
Rationale: To calculate the mL to be administered, convert 250 mg to grams (0.25 g). Then, set up a proportion: (0.25 g / 3 g) x 5 mL = 0.4167 mL, which rounds to 0.4 mL. Therefore, the healthcare professional would administer 0.4 mL per dose. Choice B (0.3 mL) is incorrect because it does not reflect the accurate calculation. Choice C (0.5 mL) is incorrect as it does not consider the correct conversion and calculation. Choice D (0.6 mL) is incorrect as it provides a value higher than the accurate calculation.
4. A nurse is preparing to assist a provider with the insertion of a nontunneled percutaneous central venous catheter into a client’s subclavian vein. Which of the following actions should the nurse take?
- A. Position the client in a high-Fowler’s position
- B. Place the client in Trendelenburg position
- C. Place a rolled towel under the client’s neck
- D. Assist the client into a side-lying position
Correct answer: B
Rationale: The correct action for the nurse to take when assisting with the insertion of a nontunneled percutaneous central venous catheter into the subclavian vein is to place the client in Trendelenburg position. This position helps distend the veins and reduces the risk of air embolism during the insertion procedure. Option A, positioning the client in a high-Fowler’s position, would not be appropriate as it does not facilitate venous distention. Option C, placing a rolled towel under the client’s neck, is not directly related to the procedure and does not serve a specific purpose in this context. Option D, assisting the client into a side-lying position, is also not the correct choice as Trendelenburg position is preferred for this procedure to aid in vein distention.
5. A nurse is caring for a client prescribed gabapentin. Which of the following should the nurse monitor?
- A. Liver function tests
- B. Renal function
- C. Blood glucose levels
- D. Cardiac rhythm
Correct answer: B
Rationale: The correct answer is B: Renal function. Gabapentin is primarily eliminated by the kidneys, so monitoring renal function is essential to ensure the drug is being cleared effectively from the body. Monitoring liver function tests (choice A) is not a priority for gabapentin as it is not primarily metabolized by the liver. Blood glucose levels (choice C) are not directly impacted by gabapentin. Cardiac rhythm (choice D) monitoring is not typically necessary for clients on gabapentin unless they have pre-existing cardiac conditions that may be exacerbated by the medication.
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