ATI LPN
PN ATI Capstone Maternal Newborn
1. During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
- A. An irregularly shaped, nontender lump palpable in the right breast
- B. Tenderness present during menstruation
- C. Bilateral, symmetrical lumps that move with palpation
- D. The client reports breast tenderness before menstruation
Correct answer: A
Rationale: An irregularly shaped, nontender lump is a concerning finding as it may indicate breast cancer. The nurse should report this finding to the provider for further investigation. Choices B, C, and D are less concerning findings. Tenderness during menstruation is a common finding due to hormonal changes. Bilateral, symmetrical lumps that move with palpation are often benign findings like fibrocystic changes. Breast tenderness before menstruation is also a common occurrence related to hormonal fluctuations.
2. Which nursing action is a priority when managing a client with a wound infection?
- A. Change the wound dressing every 24 hours
- B. Perform a wound culture before administering antibiotics
- C. Cleanse the wound with alcohol-based solutions
- D. Apply a wet-to-dry dressing to the wound
Correct answer: B
Rationale: Performing a wound culture before administering antibiotics is crucial when managing a client with a wound infection. This step helps identify the specific pathogens causing the infection, allowing for the prescription of the most effective antibiotics. Changing the wound dressing every 24 hours (Choice A) is important for wound care but not the priority when an infection is present. Cleansing the wound with alcohol-based solutions (Choice C) can be too harsh and may delay wound healing. Applying a wet-to-dry dressing (Choice D) is not recommended for infected wounds as it can cause trauma to the wound bed during dressing changes.
3. A client with pancreatitis is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of high-fat foods.
- B. I should decrease my intake of high-fat foods.
- C. I should increase my intake of high-protein foods.
- D. I should decrease my intake of high-protein foods.
Correct answer: B
Rationale: The correct answer is B. Decreasing the intake of high-fat foods is essential in managing pancreatitis as high-fat foods can exacerbate symptoms and lead to complications. By reducing high-fat foods in their diet, the client demonstrates an understanding of the dietary management needed for pancreatitis. Choices A, C, and D are incorrect. Increasing high-fat foods (Choice A) is not recommended for pancreatitis as it can worsen the condition. While high-protein foods (Choice C) can be beneficial in some cases, the primary focus in pancreatitis management is on reducing fat intake. Decreasing high-protein foods (Choice D) is not a key dietary management approach for pancreatitis.
4. A nurse is caring for a client who has a prescription for a narcotic medication. After administering, the nurse is left with an unused portion. What should the nurse do?
- A. Store the unused medication for later use
- B. Discard the medication in a regular trash bin
- C. Discard the medication with another nurse as a witness
- D. Report the unused portion to the provider
Correct answer: C
Rationale: The correct answer is to discard the medication with another nurse as a witness. Controlled substances, such as narcotic medications, must be properly disposed of to prevent misuse or diversion. Having another nurse witness the disposal ensures accountability and follows proper protocols. Storing the unused medication for later use (Choice A) is unsafe and could lead to misuse. Discarding the medication in a regular trash bin (Choice B) is inappropriate as it does not ensure proper disposal of a controlled substance. Reporting the unused portion to the provider (Choice D) is not the immediate action needed for proper medication disposal.
5. A client with a new diagnosis of hypertension is receiving teaching from a healthcare provider. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will decrease my intake of potassium.
- B. I will increase my intake of vitamin K.
- C. I will decrease my intake of sodium.
- D. I will increase my intake of magnesium.
Correct answer: C
Rationale: The correct answer is C: 'I will decrease my intake of sodium.' Lowering sodium intake is essential in managing hypertension as it helps reduce blood pressure levels. Excess sodium can lead to fluid retention and increased blood volume, putting more strain on the heart and blood vessels. Therefore, this response indicates an understanding of the teaching provided. Choices A, B, and D are incorrect because decreasing potassium intake, increasing vitamin K intake, and increasing magnesium intake are not primary dietary modifications recommended for hypertension. While potassium and magnesium can be beneficial for overall health, reducing sodium intake is the key dietary change to manage hypertension effectively.
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