ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first?
- A. A client who reports tingling in the fingers following a thyroidectomy
- B. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr
- C. A client who is in a long leg cast and reports cool feet bilaterally
- D. A client who has a productive cough and an oral temperature of 36°C (96.8°F)
Correct answer: C
Rationale: The correct answer is C. Cool feet bilaterally in a client with a long leg cast may indicate compromised circulation, which is a medical emergency that requires immediate intervention. Choices A, B, and D do not present immediate life-threatening conditions. Tingling in the fingers following a thyroidectomy may indicate hypocalcemia but does not require immediate attention. Dark, foul-smelling urine with decreased urine output indicates a possible urinary tract infection or dehydration but can be addressed after attending to the client with compromised circulation. A productive cough and a normal oral temperature do not suggest an urgent condition compared to compromised circulation in a client with a long leg cast.
2. A healthcare provider is teaching a client about the use of prednisone. Which of the following should be included?
- A. It should not be stopped abruptly
- B. It may cause weight gain
- C. It has no side effects
- D. Take it regularly regardless of symptoms
Correct answer: B
Rationale: The correct answer is B. Prednisone can cause weight gain and other side effects, so clients should be informed about these potential risks. Choice A is incorrect because prednisone should not be stopped abruptly to prevent withdrawal symptoms. Choice C is incorrect because prednisone can have various side effects. Choice D is incorrect because prednisone is usually prescribed with specific dosing instructions and should not be taken irregularly or only when symptoms occur.
3. A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safety hazard?
- A. A client’s wrist restraints tied to the bed rails
- B. A client’s bedside table placed across the foot of the bed
- C. A meal tray left at the bedside from breakfast
- D. A call light extension cord pinned to the bedspread
Correct answer: A
Rationale: The correct answer is A. Tying wrist restraints to the bed rails is a safety hazard because if the bed rails are lowered, the restraints can tighten and cause injury or asphyxiation. Choice B, placing a bedside table across the foot of the bed, may not be ideal for convenience but does not pose a direct safety hazard. Choice C, leaving a meal tray at the bedside from breakfast, is more of an infection control issue than an immediate safety hazard. Choice D, having a call light extension cord pinned to the bedspread, is also not a direct safety hazard unless it poses a risk of entanglement or tripping, which is not indicated in the scenario.
4. A healthcare professional is assessing a client who is experiencing a thyroid storm. Which of the following is an expected finding?
- A. Hypothermia
- B. Bradycardia
- C. Hypertension
- D. Lethargy
Correct answer: C
Rationale: In a thyroid storm, which is a severe complication of hyperthyroidism, hypertension is an expected finding. Other common manifestations include tachycardia, hyperthermia, and agitation. Hypothermia (choice A) is not expected in a thyroid storm as the body temperature is usually elevated due to increased metabolic rate. Bradycardia (choice B) is not typical in a thyroid storm; instead, tachycardia is more common. Lethargy (choice D) is not a typical finding in a thyroid storm, as clients are usually agitated due to excess thyroid hormone levels.
5. A client is prescribed warfarin for anticoagulation. Which of the following laboratory values should the nurse monitor?
- A. PT and INR
- B. Blood glucose levels
- C. Complete blood count (CBC)
- D. Platelet count
Correct answer: A
Rationale: The correct answer is A: PT and INR. Warfarin is an anticoagulant that affects the clotting mechanism by inhibiting vitamin K-dependent clotting factors. The PT (Prothrombin Time) and INR (International Normalized Ratio) are specific laboratory values used to monitor the effectiveness and safety of warfarin therapy. These values help healthcare providers adjust the warfarin dosage to maintain the desired level of anticoagulation. Choices B, C, and D are incorrect because blood glucose levels, complete blood count (CBC), and platelet count are not directly monitored to assess the effects of warfarin therapy.
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