a nurse overhears two assistive personnel aps discussing a client in a hospital cafeteria using the clients name and discussing details of the diagnos
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment A

1. A nurse overhears two assistive personnel (APs) discussing a client in a hospital cafeteria, using the client’s name and discussing details of the diagnosis. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: The correct action for the nurse to take first is to tell the APs to discontinue their conversation. By stopping the conversation immediately, the nurse addresses the breach of client confidentiality on the spot. This action is crucial to protect the client's privacy and confidentiality. While further steps such as reporting the behavior or providing education on confidentiality may be necessary, the immediate priority is to stop the inappropriate discussion. Reporting the behavior to the supervisor or completing an incident report can come after the immediate issue is addressed. Providing written documentation on confidentiality may be helpful but is not the most urgent action needed in this situation.

2. A client with burn injuries covering their upper body is concerned about their altered appearance. Which of the following statements should the nurse make?

Correct answer: D

Rationale: The nurse should encourage the client to attend a support group for individuals with burn injuries. Support groups can provide emotional support, promote acceptance of altered appearance, and help the client cope with the changes. Choice A is incorrect because it may not address the client's emotional needs. Choice B is incorrect as suggesting a timeline for cosmetic surgery may not be appropriate without considering the client's physical and emotional readiness. Choice C is incorrect as reconstructive surgery may not completely restore the client's previous appearance and may set unrealistic expectations.

3. A nurse in the emergency department is prioritizing care for four clients. Which of the following clients should the nurse see first?

Correct answer: D

Rationale: The client with slurred speech, disorientation, and a headache may be experiencing a stroke, a life-threatening condition that requires immediate attention. Identifying and managing a stroke promptly can reduce the risk of long-term disability or complications. The other options, although important, do not present immediate life-threatening conditions that require urgent intervention. A dislocated shoulder, severe joint pain in sickle cell disease, confusion with fever and foul-smelling urine, while concerning, can be addressed after attending to the client with potential stroke symptoms.

4. A nurse is providing discharge teaching for a client newly prescribed methadone. Which statement indicates a need for further teaching?

Correct answer: B

Rationale: The correct answer is B. Trouble sleeping is not a typical side effect of methadone; the nurse should clarify this misunderstanding. Choices A, C, and D are all correct statements regarding methadone. Methadone can indeed slow breathing, so it is important for the client to be aware of this effect. Avoiding alcohol while taking methadone is crucial due to the increased risk of central nervous system depression when alcohol is combined with methadone. Additionally, changing positions slowly can help prevent dizziness, which can be a side effect of methadone.

5. A nurse is caring for a client who has congestive heart failure and is taking digoxin. The client reports nausea and refuses to eat breakfast. Which of the following actions should the nurse take first?

Correct answer: D

Rationale: The correct answer is to check the client's apical pulse first. Nausea can be a sign of digoxin toxicity, and assessing the client's heart rate is crucial in this situation. Administering an antiemetic or encouraging the client to eat should come after ensuring the client's safety. While informing the provider is important, the immediate concern is to assess for potential digoxin toxicity by checking the client's apical pulse.

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