ATI LPN
PN ATI Capstone Maternal Newborn
1. Before an amniocentesis, what action by the client will need to be completed?
- A. Increase fluid intake
- B. Empty the bladder
- C. Avoid eating for 12 hours
- D. Take a sedative
Correct answer: B
Rationale: Before an amniocentesis, the client should empty their bladder. This is necessary to reduce the risk of bladder puncture during the procedure. A full bladder can be in the path of the needle, increasing the risk of injury. Increasing fluid intake (choice A) is not necessary before an amniocentesis. Avoiding eating for 12 hours (choice C) is not a standard preparation for an amniocentesis. Taking a sedative (choice D) is not routinely required for this procedure.
2. 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.
3. A charge nurse is providing teaching to a newly licensed nurse on how to clean surfaces contaminated with blood. Which of the following agents should the nurse include in the teaching?
- A. Hydrogen peroxide
- B. Chlorhexidine
- C. Isopropyl alcohol
- D. Chlorine bleach
Correct answer: D
Rationale: Chlorine bleach is the recommended agent for cleaning blood spills due to its effectiveness in killing bloodborne pathogens like HIV and hepatitis B. Hydrogen peroxide, Chlorhexidine, and Isopropyl alcohol are not as effective as chlorine bleach in disinfecting surfaces contaminated with blood and eliminating bloodborne pathogens, making them incorrect choices.
4. A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions should the nurse take?
- A. Apply tape to the client’s skin before surgery.
- B. Ensure the surgical suite is well-ventilated.
- C. Wrap monitoring cords with stockinette.
- D. Schedule the surgery at the end of the day.
Correct answer: C
Rationale: The correct action the nurse should take is to wrap monitoring cords with stockinette. This measure ensures that the latex in the cords does not come into contact with the client’s skin, reducing the risk of an allergic reaction. Applying tape to the client’s skin before surgery (Choice A) may expose the client to latex if the tape contains latex. Ensuring the surgical suite is well-ventilated (Choice B) is important for overall safety but does not specifically address the client's latex allergy. Scheduling the surgery at the end of the day (Choice D) is not directly related to preventing latex exposure and allergic reactions.
5. A client has a new prescription for oxcarbazepine. Which of the following should the nurse monitor?
- A. Liver function
- B. Serum sodium levels
- C. Blood glucose
- D. Heart rate
Correct answer: B
Rationale: The correct answer is B: Serum sodium levels. Oxcarbazepine can lead to hyponatremia, making it crucial to monitor serum sodium levels. Monitoring liver function (choice A) is not typically associated with oxcarbazepine use. Blood glucose (choice C) monitoring is more relevant in medications affecting blood sugar levels. Heart rate (choice D) is not directly impacted by oxcarbazepine.
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