ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A patient with chronic kidney disease reports feeling light-headed after taking their medication. What should the nurse instruct the patient to do?
- A. Take the medication with food
- B. Take the medication at bedtime
- C. Stand up slowly to prevent dizziness
- D. Increase fluid intake
Correct answer: C
Rationale: Patients with chronic kidney disease are prone to orthostatic hypotension, which can cause dizziness. To prevent this, the nurse should instruct the patient to stand up slowly. Options A, B, and D do not directly address the issue of orthostatic hypotension and dizziness in this scenario.
2. A nurse is providing teaching to a client with a new diagnosis of diabetes mellitus. Which instruction should the nurse give to the client to monitor for hypoglycemia?
- A. Monitor for polyuria
- B. Monitor for diaphoresis
- C. Monitor for abdominal pain
- D. Monitor for thirst
Correct answer: B
Rationale: The correct answer is B: 'Monitor for diaphoresis.' Diaphoresis, which refers to excessive sweating, is a common symptom of hypoglycemia. It indicates a low blood sugar level and should prompt immediate treatment. Polyuria (excessive urination), abdominal pain, and thirst are not typically associated with hypoglycemia. Polyuria is more commonly linked to hyperglycemia, while abdominal pain and thirst are not specific symptoms of hypoglycemia.
3. A 65-year-old client is taking methylprednisolone. What pharmacological action should the nurse expect with this therapy?
- A. Suppression of beta2 receptors.
- B. Suppression of airway mucus production.
- C. Fortification of bones.
- D. Suppression of candidiasis.
Correct answer: B
Rationale: The correct answer is B: 'Suppression of airway mucus production.' Methylprednisolone, a corticosteroid, is known to suppress airway mucus production. While corticosteroids can enhance the responsiveness of beta2 receptors, they are not directly involved in the suppression of these receptors (Choice A). Corticosteroids can lead to adverse effects such as bone loss, rather than fortification of bones (Choice C). They can also increase the risk of infections like candidiasis but do not directly suppress it (Choice D). Therefore, the most expected pharmacological action of methylprednisolone therapy is the suppression of airway mucus production.
4. A nurse is preparing to administer 1 unit of packed RBCs to a client. Which of the following findings should cause the nurse to delay the transfusion?
- A. Blood pressure 140/90 mm Hg
- B. Urine output of 40 mL/hr
- C. Temperature 38.2°C (100.8°F)
- D. Hemoglobin 8 g/dL
Correct answer: C
Rationale: A temperature of 38.2°C (100.8°F) suggests the possibility of an underlying infection or fever, which should be evaluated before proceeding with the transfusion to prevent complications. Elevated temperature can indicate an immune response to incompatible blood components, increasing the risk of a transfusion reaction. The other vital signs and lab results provided are within acceptable ranges for administering packed RBCs, making choices A, B, and D less likely to cause a delay in the transfusion.
5. A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?
- A. I will make sure my medications are enteric-coated.
- B. My stoma will drain liquid continuously.
- C. I will change my pouch system every two weeks.
- D. My stoma size will stay the same after it heals.
Correct answer: B
Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.
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