ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A client with hypertension is being taught about dietary modifications by a nurse. Which of the following food choices should the nurse recommend?
- A. Canned tomato soup
- B. Baked chicken breast
- C. Processed cheese
- D. Pickled vegetables
Correct answer: B
Rationale: The correct answer is Baked chicken breast. It is low in sodium and a healthy option for clients with hypertension. Canned tomato soup and processed cheese are typically high in sodium, which is not recommended for individuals with hypertension. Pickled vegetables are also high in sodium and should be avoided in a hypertension-friendly diet.
2. A client is being educated about the use of spironolactone. Which of the following should be included in the teaching?
- A. Avoid potassium-rich foods
- B. Take the medication with food
- C. Monitor for signs of toxicity
- D. Discontinue the medication if potassium levels rise
Correct answer: A
Rationale: The correct answer is A: Avoid potassium-rich foods. Spironolactone can lead to hyperkalemia, a condition characterized by high levels of potassium in the blood. To prevent this complication, clients taking spironolactone should avoid potassium-rich foods. Choice B is incorrect because spironolactone can be taken with or without food. Choice C is not directly related to spironolactone use, as toxicity monitoring is not a specific concern with this medication. Choice D is incorrect because discontinuing the medication solely based on elevated potassium levels may not be necessary; instead, dosage adjustments or potassium restriction are often more appropriate.
3. A nurse in an emergency department is serving on a committee that is reviewing the facility protocol for disaster readiness. The nurse should recommend that the protocol include which of the following as a clinical manifestation of smallpox?
- A. Bloody diarrhea
- B. Ptosis of the eyelids
- C. Descending paralysis
- D. Rash in the mouth
Correct answer: D
Rationale: The correct answer is D, 'Rash in the mouth.' Smallpox presents with a distinctive rash that typically begins in the mouth and spreads to the rest of the body, developing into pustules. This rash is a key clinical manifestation of smallpox. This infectious disease is characterized by the rash, fever, and other systemic symptoms. Choices A, B, and C are incorrect because they are not associated with smallpox. Bloody diarrhea, ptosis of the eyelids, and descending paralysis are not typical clinical manifestations of smallpox.
4. A nurse is assessing a 1-hour postpartum client and notes a boggy uterus located 2 cm above the umbilicus. Which of the following actions should the nurse take first?
- A. Take vital signs
- B. Assess lochia
- C. Massage the fundus
- D. Give oxytocin IV bolus
Correct answer: C
Rationale: When a nurse assesses a 1-hour postpartum client with a boggy uterus located 2 cm above the umbilicus, it indicates uterine atony. The first action the nurse should take is to massage the fundus. Fundal massage helps stimulate uterine contractions, which will reduce bleeding and prevent postpartum hemorrhage. Taking vital signs, assessing lochia, or administering an oxytocin IV bolus are important interventions but should come after addressing uterine atony through fundal massage.
5. A nurse is preparing to administer a dose of insulin. Which of the following should the nurse do first?
- A. Check the expiration date
- B. Verify the client's blood glucose level
- C. Obtain the client's weight
- D. Assess for signs of hypoglycemia
Correct answer: B
Rationale: The correct answer is to verify the client's blood glucose level first before administering insulin. This step is crucial to determine the appropriate dose of insulin based on the client's current blood glucose level. Checking the expiration date (Choice A) is important but not the first step in this scenario. Obtaining the client's weight (Choice C) is not directly related to the immediate administration of insulin. Assessing for signs of hypoglycemia (Choice D) should be done after administering insulin to monitor for potential side effects or adverse reactions.
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