ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is teaching a client who is lactose intolerant about dietary choices. Which food should the nurse recommend to increase calcium intake?
- A. Spinach
- B. Peanut butter
- C. Ground beef
- D. Carrots
Correct answer: A
Rationale: The correct answer is A: Spinach. Spinach is rich in calcium, making it a suitable choice for individuals with lactose intolerance who need to avoid dairy products. Peanut butter, ground beef, and carrots are not significant sources of calcium compared to spinach, and therefore, not the best recommendation for increasing calcium intake in lactose-intolerant individuals.
2. A community health nurse is teaching a group of clients about first aid for wounds. Which client statement indicates understanding?
- A. Remove blood-saturated dressings
- B. Apply clean dressings over the saturated ones and hold pressure
- C. Elevate the wound above heart level
- D. Leave the wound open to air
Correct answer: B
Rationale: The correct answer is B. Applying clean dressings over blood-saturated ones and holding pressure helps to control bleeding and prevent tissue disruption. Removing blood-saturated dressings can cause further damage by disrupting the forming clot. Elevating the wound above heart level is beneficial to reduce swelling, but it is not the best immediate action for a blood-saturated dressing. Leaving the wound open to air can increase the risk of infection and slow down the healing process.
3. A nurse is assessing a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?
- A. Blood glucose 120 mg/dL
- B. pH 7.32
- C. HCO3 25 mEq/L
- D. PaCO2 48 mm Hg
Correct answer: B
Rationale: The correct answer is B. A pH of 7.32 indicates metabolic acidosis, which is a hallmark of diabetic ketoacidosis (DKA). In DKA, blood glucose levels are typically elevated, bicarbonate levels are often low, and there is a compensatory respiratory response leading to a decrease in PaCO2. Option A is incorrect because a blood glucose level of 120 mg/dL is within the normal range and not indicative of DKA. Option C is incorrect because an HCO3 level of 25 mEq/L is not typically seen in DKA where bicarbonate levels are usually lower. Option D is incorrect because a PaCO2 of 48 mm Hg would not be expected in DKA; it would typically be lower due to compensatory respiratory alkalosis.
4. A nurse is teaching about measures to promote sleep for a client with insomnia. What statement indicates understanding?
- A. I should reduce my fluid intake to 2 hours before bedtime
- B. I will watch TV in bed before sleeping
- C. I can take long naps during the day
- D. I should exercise right before going to bed
Correct answer: A
Rationale: The correct answer is A. Reducing fluid intake to 2-4 hours before sleeping helps prevent interruptions during the night, promoting better sleep. Watching TV in bed before sleeping (choice B) can actually hinder sleep due to the stimulation from screens. Taking long naps during the day (choice C) can disrupt the natural sleep-wake cycle. Exercising right before going to bed (choice D) can increase alertness and make it harder to fall asleep.
5. When caring for a client prescribed azithromycin, what should the nurse monitor?
- A. Liver function
- B. Signs of diarrhea
- C. Blood glucose levels
- D. Serum electrolytes
Correct answer: B
Rationale: The correct answer is to monitor signs of diarrhea when a client is prescribed azithromycin. Azithromycin is known to cause gastrointestinal side effects, particularly diarrhea. Monitoring for diarrhea is crucial to assess the client's response to the medication and to prevent complications such as dehydration. Monitoring liver function (choice A), blood glucose levels (choice C), and serum electrolytes (choice D) are not typically indicated specifically for clients prescribed azithromycin unless there are other specific reasons or conditions that warrant such monitoring.
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