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. What are the risk factors for deep vein thrombosis (DVT) and how can it be prevented?
- A. Immobility and oral contraceptive use
- B. Pregnancy and smoking
- C. Obesity and varicose veins
- D. Hypertension and high cholesterol
Correct answer: A
Rationale: The correct answer is A: Immobility and oral contraceptive use. Immobility and oral contraceptive use are significant risk factors for deep vein thrombosis (DVT). Immobility leads to blood stasis, increasing the risk of clot formation, while oral contraceptive use can promote hypercoagulability. Prevention strategies for DVT include promoting mobility to enhance blood circulation and using anticoagulants to prevent clot formation. Choices B, C, and D are incorrect. While pregnancy and smoking can increase the risk of DVT, they are not the specific factors mentioned in the question. Similarly, obesity and varicose veins, as well as hypertension and high cholesterol, are not the primary risk factors associated with DVT.
3. When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations?
- A. Blood-tinged sputum
- B. Dizziness
- C. Pallor
- D. Somnolence
Correct answer: B
Rationale: Corrected Question: When caring for a client receiving nifedipine for prevention of preterm labor, the nurse should monitor the client for which of the following manifestations? Rationale: Nifedipine, a calcium channel blocker, causes vasodilation, potentially leading to a decrease in blood pressure and side effects such as dizziness. Monitoring for dizziness is essential to ensure the client's safety and well-being during treatment. Choices A, C, and D are incorrect as they are not typically associated with nifedipine use for preventing preterm labor. Blood-tinged sputum may indicate other conditions like pulmonary issues, pallor could suggest anemia or circulatory problems, and somnolence is not a common side effect of nifedipine.
4. A patient with atrial fibrillation is prescribed warfarin. Which laboratory test should the nurse monitor to assess the effectiveness of the medication?
- A. Complete blood count (CBC)
- B. Prothrombin time (PT)/INR
- C. Partial thromboplastin time (PTT)
- D. Serum potassium level
Correct answer: B
Rationale: The correct answer is B: Prothrombin time (PT)/INR. Warfarin affects the clotting ability of the blood by inhibiting vitamin K-dependent clotting factors. Monitoring the prothrombin time (PT) and international normalized ratio (INR) is crucial to assess the effectiveness and safety of warfarin therapy. These tests help determine if the patient is within the desired anticoagulation range to prevent either clotting issues or excessive bleeding.
5. A client is being taught about the use of levothyroxine. Which of the following should be included in the teaching?
- A. Take it with food
- B. Take it at the same time every day
- C. It can be stopped suddenly
- D. Monitor for hyperglycemia
Correct answer: B
Rationale: The correct answer is B: 'Take it at the same time every day.' It is important to take levothyroxine consistently at the same time each day to maintain stable thyroid hormone levels. Choice A is incorrect as levothyroxine should be taken on an empty stomach for better absorption. Choice C is incorrect because stopping levothyroxine suddenly can lead to adverse effects due to sudden changes in hormone levels. Choice D is also incorrect as hyperglycemia is not a common side effect associated with levothyroxine.
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