ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is teaching a group of clients about stress management. Which of the following activities should the nurse recommend to reduce stress?
- A. Watching television
- B. Deep breathing exercises
- C. Drinking coffee
- D. Avoiding exercise
Correct answer: B
Rationale: Deep breathing exercises are effective in reducing stress by promoting relaxation and lowering heart rate, making them a recommended technique. Watching television may not actively reduce stress but can serve as a distraction. Drinking coffee, which contains caffeine, may increase anxiety levels. Avoiding exercise can lead to pent-up stress and tension rather than reducing it.
2. A client with staphylococcus epidermidis is prescribed vancomycin. Identify the adverse effect associated with this antibiotic therapy.
- A. Hepatotoxicity
- B. Constipation
- C. Infusion reaction
- D. Immunosuppression
Correct answer: C
Rationale: The correct adverse effect associated with vancomycin therapy is an infusion reaction, known as Red Man Syndrome. This reaction presents with rashes, flushing, tachycardia, and hypotension. It is essential to administer vancomycin over at least 60 minutes to prevent these symptoms. Hepatotoxicity, constipation, and immunosuppression are not commonly associated with vancomycin use. Ototoxicity and renal toxicity are significant risks with prolonged vancomycin therapy.
3. A healthcare professional is preparing to administer a dose of naloxone. Which of the following should the healthcare professional assess?
- A. Heart rate
- B. Respiratory rate
- C. Blood pressure
- D. Temperature
Correct answer: B
Rationale: Correct. Naloxone is used to reverse opioid overdose, which can cause respiratory depression. Assessing the respiratory rate before administering naloxone is crucial to monitor the patient's breathing. Choices A, C, and D are important assessments in general patient care but are not specifically crucial before administering naloxone for opioid overdose.
4. A client with a new diagnosis of heart failure is prescribed furosemide. Which of the following instructions should the nurse include?
- A. Take the medication in the morning.
- B. Increase intake of potassium-rich foods.
- C. Report a decrease in urine output.
- D. Expect swelling in the lower extremities.
Correct answer: B
Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide, a loop diuretic, can lead to potassium loss, which may cause hypokalemia. Increasing potassium intake can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide is usually taken in the morning to prevent sleep disturbances due to increased urination. Choice C is incorrect because a decrease in urine output could indicate a problem and should be reported immediately. Choice D is incorrect because furosemide is used to reduce swelling in the body, including the lower extremities, so expecting swelling is not appropriate.
5. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?
- A. “Lie on your left side.”
- B. “Lie on your right side.”
- C. “Increase your fluid intake.”
- D. “Decrease your fluid intake.”
Correct answer: B
Rationale: Following a liver biopsy, the nurse should instruct the client to lie on the right side to promote hemostasis. This position helps apply pressure to the biopsy site, reducing the risk of bleeding. Instructing the client to lie on the left side (Choice A) would not provide the same benefit. Increasing fluid intake (Choice C) is generally beneficial post-procedure to prevent dehydration and promote healing. Decreasing fluid intake (Choice D) is not advisable as it can lead to dehydration and potential complications.
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