ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A client with diabetes mellitus is receiving education on foot care. Which of the following instructions should the nurse include?
- A. Apply lotion between the toes.
- B. Cut toenails straight across.
- C. Use a heating pad to warm the feet.
- D. Soak feet in warm water daily.
Correct answer: B
Rationale: The correct answer is B: Cut toenails straight across. This instruction is vital for clients with diabetes as it helps prevent ingrown toenails and infections, reducing the risk of foot ulcers. Applying lotion between the toes (choice A) should be avoided as it can create a moist environment prone to fungal infections. Using a heating pad (choice C) can lead to burns or injuries due to reduced sensation common in diabetes. Soaking feet in warm water daily (choice D) can also increase the risk of skin breakdown and should be avoided.
2. While receiving a change of shift report on a group of clients, which patient should the nurse assess first?
- A. The client who has a fractured femur and reports sharp chest pain.
- B. The client who has a fever and is receiving antibiotics.
- C. The client who has a urinary tract infection and reports pain with urination.
- D. The client who is scheduled for surgery in the afternoon.
Correct answer: A
Rationale: The nurse should assess the client with a fractured femur and sharp chest pain first. Sharp chest pain in this client may indicate a pulmonary embolism, a life-threatening condition requiring immediate attention. The other options describe important patient conditions but do not pose an immediate threat to life like a potential pulmonary embolism does.
3. A nurse is completing an assessment of a newborn who is 2 hours old. Which of the following findings is indicative of cold stress?
- A. Respiratory rate of 60 per minute
- B. Jitteriness of the hands
- C. Diaphoresis
- D. Bounding peripheral pulses
Correct answer: B
Rationale: Jitteriness of the hands is a classic sign of cold stress in newborns, indicating that the infant is having difficulty maintaining a stable body temperature. Cold stress can lead to hypoglycemia and increased oxygen consumption. The other options (A, C, and D) are not directly associated with cold stress in newborns. A respiratory rate of 60 per minute may be within the normal range for a newborn. Diaphoresis (excessive sweating) and bounding peripheral pulses are not specific signs of cold stress in newborns.
4. A healthcare provider is teaching a client about the use of sertraline. Which of the following should be included?
- A. It can cause weight gain
- B. It is an antipsychotic
- C. Monitor for suicidal thoughts
- D. It has no side effects
Correct answer: C
Rationale: Correct answer: Monitoring for suicidal thoughts is essential when a client is prescribed sertraline, an antidepressant. Choice A is incorrect because weight gain is not typically associated with sertraline. Choice B is incorrect as sertraline is not an antipsychotic medication. Choice D is incorrect because all medications, including sertraline, have potential side effects.
5. A client who is at 32 weeks gestation and has a history of cardiac disease is being cared for by a nurse. Which of the following positions should the nurse place the client in to best promote optimal cardiac output?
- A. The chest
- B. Standing
- C. Supine
- D. Left lateral
Correct answer: D
Rationale: The correct answer is the left lateral position. Placing the client in the left lateral position promotes optimal cardiac output during pregnancy by reducing pressure on the inferior vena cava, improving blood flow to the heart and fetus. Choice A, 'The chest,' is incorrect as it does not describe a position that benefits cardiac output. Choice B, 'Standing,' is incorrect as it does not alleviate pressure on the vena cava. Choice C, 'Supine,' is contraindicated in pregnancy, especially in clients with cardiac disease, as it can compress the vena cava and decrease cardiac output.
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