ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A client has been prescribed albuterol. Which of the following is a priority adverse effect the nurse should monitor?
- A. Tachycardia
- B. Bradycardia
- C. Dizziness
- D. Hypertension
Correct answer: A
Rationale: Corrected Rationale: Albuterol, a beta-2 adrenergic agonist, can lead to tachycardia due to its stimulant effect on beta-2 receptors in the heart. Monitoring for tachycardia is crucial as it can be a sign of excessive sympathetic stimulation and may lead to severe complications. Bradycardia, dizziness, and hypertension are less likely adverse effects of albuterol, making them lower priority for monitoring in this context.
2. A nurse is caring for a client with deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Position the client with the affected leg below the heart
- B. Massage the affected extremity every 4 hours
- C. Apply cold compresses to the affected extremity
- D. Elevate the affected leg while in bed
Correct answer: D
Rationale: The correct answer is to elevate the affected leg while in bed. Elevating the leg helps reduce swelling and promotes venous return, aiding in the management of DVT. Positioning the affected leg below the heart can worsen the condition by increasing the risk of clot dislodgment. Massaging the affected extremity can also dislodge the clot and should be avoided. Cold compresses are not recommended as they can cause vasoconstriction, potentially worsening the condition.
3. When a nurse is interviewing a client who is requesting oral contraceptives, which finding in the client’s history is a contraindication to combined oral contraceptives?
- A. Thyroid disease
- B. Allergy to penicillin
- C. Impaired liver function
- D. Abnormal blood glucose levels
Correct answer: C
Rationale: The correct answer is C: Impaired liver function. Impaired liver function is a contraindication to the use of oral contraceptives because they are metabolized in the liver. Choices A, B, and D are incorrect. Thyroid disease, allergy to penicillin, and abnormal blood glucose levels are not contraindications to combined oral contraceptives.
4. A nurse is preparing a client for transfer to another unit. Which finding should the nurse include in the transfer report?
- A. Response to pain medication
- B. Review of ongoing discharge plan
- C. Recent physical changes
- D. All of the above
Correct answer: D
Rationale: When preparing a client for transfer to another unit, the nurse should include all the findings mentioned in the choices in the transfer report. It is crucial to document the client's response to pain medication as it helps the receiving unit manage the client's pain effectively. Reviewing the ongoing discharge plan ensures that the client's care continues seamlessly after the transfer. Noting recent physical changes is vital for the receiving unit to monitor the client's condition accurately. Therefore, all of the above findings are essential for ensuring continuity of care and providing comprehensive information to the receiving unit.
5. A menopausal client is having difficulty getting to sleep and asks what actions she should incorporate into her daily routine to promote sleep. The nurse would encourage which of the following measures to promote sleep?
- A. Consume a warm drink at bedtime
- B. Take an evening walk before bedtime
- C. Take an afternoon nap
- D. Limit alcohol and nicotine prior to bedtime
Correct answer: D
Rationale: The correct answer is D: Limit alcohol and nicotine prior to bedtime. Alcohol and nicotine are stimulants that can disrupt sleep patterns, so avoiding them before bedtime can promote better sleep. Choices A, B, and C are incorrect. Consuming a warm drink at bedtime may lead to frequent urination, disrupting sleep; taking an evening walk before bedtime may increase alertness rather than inducing sleep; and taking an afternoon nap can make it harder to fall asleep at night.
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