LPN LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client with a history of heroin use who is intoxicated. Which finding should the nurse expect?
- A. Constricted pupils
- B. Dilated pupils
- C. Increased reflexes
- D. Elevated blood pressure
Correct answer: A
Rationale: The correct answer is A: Constricted pupils. Constricted pupils are a classic sign of opioid intoxication, including heroin. Opioids like heroin cause the pupils to constrict due to their effect on the autonomic nervous system. Dilated pupils, increased reflexes, and elevated blood pressure are not typically associated with opioid intoxication but may be seen with other substances or conditions.
2. A nurse is assessing a 2-hour-old newborn for cold stress. Which of the following findings should the nurse expect?
- A. Respiratory rate of 60/min
- B. Jitteriness of the hands
- C. Diaphoresis
- D. Bounding peripheral pulses
Correct answer: B
Rationale: The correct answer is B: Jitteriness of the hands. Jitteriness is a key sign of cold stress in a newborn, indicating the need for immediate warming measures. A respiratory rate of 60/min may not be directly indicative of cold stress. Diaphoresis (excessive sweating) and bounding peripheral pulses are not typical findings associated with cold stress in newborns.
3. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?
- A. Position the client with the affected extremity lower than the heart
- B. Administer acetaminophen for pain
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct answer: D
Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.
4. A nurse is caring for a client who is in preterm labor and is receiving magnesium sulfate via IV infusion. Which of the following findings indicates magnesium toxicity?
- A. Blood glucose of 150 mg/dL
- B. Urine output of 20 mL/hour
- C. Systolic blood pressure of 140 mm Hg
- D. BUN 20 mg/dL
Correct answer: B
Rationale: The correct answer is B. A urine output of 20 mL/hour is a sign of magnesium toxicity because decreased urine output can lead to accumulation of magnesium. Choices A, C, and D are not indicators of magnesium toxicity. Elevated blood glucose, high systolic blood pressure, and normal BUN levels do not specifically point towards magnesium toxicity.
5. A client with lactose intolerance needs to increase calcium intake. Which food should the nurse recommend?
- A. Spinach
- B. Peanut butter
- C. Ground beef
- D. Carrots
Correct answer: A
Rationale: Spinach is a suitable choice to recommend for increasing calcium intake to a client with lactose intolerance. Spinach is a good non-dairy source of calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium. Peanut butter is high in protein and fats, ground beef is a source of protein and iron, and carrots are rich in vitamin A and fiber, but none of these choices provide a substantial amount of calcium.
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