ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following is an appropriate description of the use of hypnosis during labor?
- A. Hypnosis focuses on biofeedback as a relaxation technique
- B. Hypnosis promotes increased control of pain perception during contractions
- C. Hypnosis uses therapeutic touch to reduce anxiety during labor
- D. Hypnosis provides instruction to minimize pain
Correct answer: B
Rationale: The correct answer is B. Hypnosis during labor helps the client gain increased control over her perception of pain, allowing for better pain management during contractions. Choice A is incorrect because hypnosis and biofeedback are distinct techniques. Choice C is incorrect as therapeutic touch and hypnosis are different modalities. Choice D is incorrect as hypnosis does not simply provide instruction to minimize pain, but rather helps the individual control their perception of pain.
2. A nurse is providing dietary teaching to a client who is at risk for cardiovascular disease. Which of the following foods should the nurse recommend?
- A. Fried chicken
- B. Oatmeal
- C. Bacon
- D. Whole milk
Correct answer: B
Rationale: Oatmeal is high in fiber, which helps lower cholesterol levels, making it a heart-healthy food option for clients at risk for cardiovascular disease. Fried chicken, bacon, and whole milk are high in saturated fats and cholesterol, which can increase the risk of heart disease and should be limited in the diet of individuals at risk for cardiovascular issues.
3. A client is receiving IV moderate sedation with midazolam and has a respiratory rate of 9/min. What should the nurse do?
- A. Place the client in a prone position
- B. Implement positive pressure ventilation
- C. Perform nasopharyngeal suctioning
- D. Administer flumazenil
Correct answer: D
Rationale: The correct answer is D: Administer flumazenil. Flumazenil is the reversal agent for midazolam, a benzodiazepine, and should be administered to counteract respiratory depression. Placing the client in a prone position (choice A) could further compromise their breathing. Implementing positive pressure ventilation (choice B) is not indicated as the first step when dealing with respiratory depression due to sedation. Performing nasopharyngeal suctioning (choice C) is not appropriate in this situation where the client is experiencing respiratory depression due to medication sedation.
4. A client has been prescribed metoclopramide. Which of the following should the nurse include in client education regarding this medication?
- A. Notify your provider if you experience restlessness or spasms of the face or neck.
- B. Take the medication only if you feel nauseous.
- C. Avoid drinking any fluids while taking this medication.
- D. Take the medication on an empty stomach.
Correct answer: A
Rationale: The correct answer is A: 'Notify your provider if you experience restlessness or spasms of the face or neck.' Metoclopramide can cause extrapyramidal symptoms, such as restlessness and muscle spasms, particularly of the face and neck. These symptoms should be reported to the provider immediately. Choice B is incorrect because metoclopramide is not meant to be taken only when feeling nauseous; it is used to treat nausea and vomiting. Choice C is incorrect because it is important to stay hydrated while taking metoclopramide. Choice D is incorrect because metoclopramide is usually taken before meals to improve gastric emptying, not necessarily on an empty stomach.
5. In the nursing process, the evaluation phase is used to determine:
- A. Value of the nursing intervention
- B. Accuracy of problem identification
- C. Quality of the plan of care
- D. Degree of outcome achievement
Correct answer: D
Rationale: The evaluation phase of the nursing process is used to determine the degree of outcome achievement. It assesses whether the goals and outcomes set during the planning phase were met. Choice A is incorrect because it focuses on the worth of the intervention rather than the achievement of outcomes. Choice B is incorrect as it pertains to the assessment phase where problems are identified. Choice C is incorrect as it refers to the planning phase where the care plan is developed, not evaluated.
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