ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is teaching a client with newly diagnosed hypertension about lifestyle changes. Which of the following recommendations should the nurse make?
- A. Limit sodium intake to 3,000 mg per day.
- B. Exercise for at least 30 minutes most days of the week.
- C. Drink no more than two alcoholic drinks per day.
- D. Increase fluid intake to at least 3 liters per day.
Correct answer: B
Rationale: The correct answer is B: 'Exercise for at least 30 minutes most days of the week.' Regular exercise, especially aerobic activity, is known to help lower blood pressure and should be included in lifestyle changes for managing hypertension. Choice A is incorrect because the recommended sodium intake for individuals with hypertension is usually lower than 3,000 mg per day. Choice C is incorrect as it is advisable to limit alcohol intake to one drink per day for women and two drinks per day for men. Choice D is incorrect because increasing fluid intake to 3 liters per day may not be necessary and could be harmful in some cases, depending on the individual's health status.
2. A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take?
- A. Wear sterile gloves when removing the old dressing
- B. Warm the irrigation solution to 40.5°C (105°F)
- C. Cleanse the wound from the center outwards
- D. Use a 20 mL syringe to irrigate the wound
Correct answer: C
Rationale: The correct action for the nurse to take when caring for a client with a prescription for wound irrigation is to cleanse the wound from the center outwards. This technique helps prevent contamination by pushing debris away from the wound rather than into it. Choice A is incorrect because wearing sterile gloves is important during wound care but not specifically mentioned for wound irrigation. Choice B is incorrect because warming the irrigation solution to a specific temperature is not a standard recommendation and can potentially harm the client. Choice D is incorrect because the size of the syringe may vary based on the wound size and depth, so using a 20 mL syringe is not a universal guideline.
3. A healthcare provider is assessing a client who has anemia. Which of the following findings should the healthcare provider expect?
- A. Bradycardia.
- B. Pallor.
- C. Hypertension.
- D. Jaundice.
Correct answer: B
Rationale: Pallor is a common finding in clients with anemia due to decreased hemoglobin levels. Anemia leads to reduced oxygen-carrying capacity in the blood, resulting in pale skin and mucous membranes, which is known as pallor. Bradycardia, hypertension, and jaundice are typically not associated with anemia.
4. A nurse is performing a vaginal exam on a client who is in active labor. The nurse notes the umbilical cord protruding through the cervix. Which of the following actions should the nurse take?
- A. Administer oxytocin to the client via intravenous infusion
- B. Apply oxygen at 2 L/min via nasal cannula
- C. Prepare for insertion of an intrauterine pressure catheter
- D. Assist the client into the knee-chest position
Correct answer: D
Rationale: The nurse should assist the client into the knee-chest position to relieve pressure on the umbilical cord. This position helps to prevent cord compression and improves fetal oxygenation. Administering oxytocin (Choice A) could worsen the situation by increasing contractions and potentially compressing the umbilical cord. Applying oxygen (Choice B) is not the priority in this emergency situation. Preparing for insertion of an intrauterine pressure catheter (Choice C) is not appropriate as the immediate concern is relieving pressure on the umbilical cord.
5. A nurse is caring for a client who has a new prescription for amphotericin B. The nurse should plan to monitor the client for which of the following adverse effects?
- A. Hyperkalemia
- B. Hypertension
- C. Constipation
- D. Nephrotoxicity
Correct answer: D
Rationale: Correct. Amphotericin B is known for its nephrotoxicity, which can lead to kidney damage. Monitoring kidney function is crucial to detect any signs of nephrotoxicity early. Choices A, B, and C are incorrect because hyperkalemia, hypertension, and constipation are not typically associated with amphotericin B use. Therefore, the nurse should focus on monitoring for nephrotoxicity.
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