ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. 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.
2. A healthcare professional is preparing to administer morphine for severe pain. What is the priority assessment the professional should make before administration?
- A. Blood pressure
- B. Respiratory rate
- C. Heart rate
- D. Temperature
Correct answer: B
Rationale: Before administering morphine, the priority assessment the healthcare professional should make is the client's respiratory rate. Morphine can cause respiratory depression, so assessing the respiratory rate is crucial to prevent any potential complications. Assessing blood pressure, heart rate, and temperature are important as well, but they are not the priority when administering morphine for severe pain.
3. A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?
- A. Proceed with the dressing change
- B. Restart the procedure if the sterile solution splashes onto the sterile field
- C. Continue without concern for minor splashes
- D. Delegate the task to another nurse
Correct answer: B
Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.
4. A healthcare provider is reviewing laboratory values for a client who reports fatigue and cold intolerance. The client has an increased thyroid-stimulating hormone (TSH) level and a decreased total T3 and T4 level. The healthcare provider should anticipate a prescription for which of the following medications?
- A. Methimazole
- B. Somatropin
- C. Levothyroxine
- D. Propylthiouracil
Correct answer: C
Rationale: The client’s symptoms and lab results indicate hypothyroidism, and levothyroxine is the standard treatment to replace the deficient thyroid hormones. Methimazole and propylthiouracil are used to treat hyperthyroidism by decreasing the production of thyroid hormones. Somatropin is a growth hormone used in conditions of growth hormone deficiency, not for hypothyroidism.
5. A client with HIV and neutropenia requires specific care from the nurse. Which of the following precautions should the nurse take while caring for this client?
- A. Wear an N95 respirator while caring for the client.
- B. Use a dedicated stethoscope for the client.
- C. Insert an indwelling urinary catheter to monitor urinary output.
- D. Monitor the client’s vital signs every 8 hours.
Correct answer: B
Rationale: Using dedicated equipment for a neutropenic client, such as a stethoscope, helps prevent infections. Neutropenic clients have a weakened immune system, making them vulnerable to infections from common pathogens. Wearing an N95 respirator is not necessary unless airborne precautions are required. Inserting a urinary catheter should be avoided unless necessary to prevent introducing pathogens. Monitoring vital signs should be done more frequently, typically every 4 hours, to promptly identify any changes in the client's condition.
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