ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A nurse is teaching a client about the use of omeprazole. Which of the following should be included?
- A. Take the medication with food
- B. Avoid taking it with NSAIDs
- C. Monitor for gastrointestinal bleeding
- D. It can cause drowsiness
Correct answer: C
Rationale: The correct answer is C. Omeprazole is a proton pump inhibitor that can mask symptoms of gastrointestinal bleeding; clients should be monitored for this. Choices A and B are incorrect because omeprazole is usually taken before meals, and while it is important to avoid NSAIDs if possible due to their effects on the stomach, it is not directly related to omeprazole use. Choice D is also incorrect as omeprazole is not typically associated with causing drowsiness.
2. A nurse is caring for a client with a chest tube following a thoracotomy. Which of the following findings requires intervention by the nurse?
- A. Tidaling with spontaneous respirations
- B. Drainage collection chamber is 1/3 full
- C. 1 cm of water present in the water seal chamber
- D. Suction chamber pressure of -20 cm H2O
Correct answer: C
Rationale: 1 cm of water in the water seal chamber is insufficient to ensure proper functioning of the chest tube. The water seal chamber typically requires a water level of 2 cm. Tidaling with spontaneous respirations (choice A) is an expected finding indicating proper functioning. Having the drainage collection chamber 1/3 full (choice B) is within the normal range. A suction chamber pressure of -20 cm H2O (choice D) is an appropriate level for chest tube drainage.
3. While caring for a client receiving patient-controlled analgesia (PCA), which of the following interventions should the nurse take?
- A. Encourage the client to use the PCA before dressing changes.
- B. Monitor the client's respiratory status.
- C. Provide oxygen therapy to the client as needed.
- D. Ensure the PCA pump is functioning properly.
Correct answer: A
Rationale: Corrected Rationale: The nurse should encourage the client to use the PCA pump before activities like dressing changes, which are likely to cause pain, to ensure effective pain management. Monitoring the client's respiratory status (Choice B) is important but not the priority in this scenario. Providing oxygen therapy (Choice C) is not a routine intervention for all clients on PCA unless specifically indicated. Ensuring the PCA pump is functioning properly (Choice D) is essential, but encouraging the client to use the PCA before painful activities takes precedence to manage pain effectively.
4. A client with a new diagnosis of heart failure is prescribed furosemide. Which of the following instructions should the nurse include?
- A. Take the medication in the morning.
- B. Increase intake of potassium-rich foods.
- C. Report a decrease in urine output.
- D. Expect swelling in the lower extremities.
Correct answer: B
Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide, a loop diuretic, can lead to potassium loss, which may cause hypokalemia. Increasing potassium intake can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide is usually taken in the morning to prevent sleep disturbances due to increased urination. Choice C is incorrect because a decrease in urine output could indicate a problem and should be reported immediately. Choice D is incorrect because furosemide is used to reduce swelling in the body, including the lower extremities, so expecting swelling is not appropriate.
5. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which is a contraindication for this vaccine?
- A. Recent blood transfusion
- B. Allergy to penicillin
- C. Minor acute illness
- D. Low-grade fever
Correct answer: A
Rationale: The correct answer is A: Recent blood transfusion. A recent blood transfusion can interfere with the effectiveness of the MMR vaccine, making it a contraindication. Choice B, allergy to penicillin, is not a contraindication for the MMR vaccine. Choice C, minor acute illness, is not a contraindication unless the child has a moderate to severe illness. Choice D, low-grade fever, is not a contraindication as long as the child does not have a moderate to severe febrile illness.
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