ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A client is prescribed digoxin for heart failure. Which of the following should the nurse monitor to evaluate the effectiveness of the medication?
- A. Respiratory rate
- B. Blood pressure
- C. Apical pulse
- D. Urine output
Correct answer: C
Rationale: The correct answer is C: Apical pulse. Digoxin's primary effect is to strengthen the force of the heart's contractions and slow the heart rate. Monitoring the apical pulse is crucial in evaluating the effectiveness of digoxin as it helps assess the medication's impact on the heart's function. Option A, respiratory rate, is not directly related to digoxin's mechanism of action and is not the most appropriate parameter to monitor for this medication. Option B, blood pressure, while important, may not be as sensitive as the apical pulse in assessing the effectiveness of digoxin. Option D, urine output, is more indicative of kidney function and fluid balance, rather than the direct effectiveness of digoxin in heart failure.
2. A client has been prescribed ferrous sulfate. Which instruction should the nurse provide to the client?
- A. Avoid strawberries, citrus fruits, and melon to improve absorption
- B. Take with fluids other than coffee or tea
- C. Take on a full stomach
- D. Double the dose if you miss a dose one day
Correct answer: B
Rationale: The correct instruction the nurse should provide to a client prescribed ferrous sulfate is to take it with fluids other than coffee or tea. Coffee and tea can inhibit iron absorption. Therefore, choices A, C, and D are incorrect. Avoiding strawberries, citrus fruits, and melon is not necessary for improving absorption of ferrous sulfate, taking it on a full stomach is not recommended, and doubling the dose if a dose is missed can lead to an overdose.
3. A healthcare professional is preparing to transfer a client from a chair to a bed. The client can bear partial weight and has upper body strength. Which device should the healthcare professional use?
- A. Hydraulic lift
- B. Stand-assist lift
- C. Wheelchair
- D. Mechanical lift
Correct answer: B
Rationale: A stand-assist lift is the appropriate device for transferring a client who can bear partial weight and has upper body strength. This device provides support for the client to stand up and be transferred safely. A hydraulic lift is more suitable for transferring clients who cannot bear weight. A wheelchair is used for mobility but not for transferring between a chair and a bed. A mechanical lift is typically used for transferring clients who are unable to bear weight or have limited mobility.
4. A nurse is caring for a client prescribed metoprolol. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Bradycardia
- B. Hypotension
- C. Tachycardia
- D. Hyperglycemia
Correct answer: B
Rationale: The correct answer is B: Hypotension. Metoprolol, a beta-blocker, can lead to a decrease in blood pressure, resulting in hypotension. Monitoring blood pressure regularly is essential to detect and manage this adverse effect. Choices A, C, and D are incorrect because metoprolol typically does not cause bradycardia, tachycardia, or hyperglycemia as its primary adverse effects.
5. A nurse is preparing to administer 2.5 mL of medication intramuscularly to an adult client. Which site is safest for the nurse to use?
- A. Ventrogluteal
- B. Dorsogluteal
- C. Vastus lateralis
- D. Rectus femoris
Correct answer: A
Rationale: The correct answer is 'Ventrogluteal.' The ventrogluteal site is recommended for intramuscular injections in adults because it is free of major blood vessels and nerves, reducing the risk of injury or complications. Choice B, 'Dorsogluteal,' is not recommended due to the proximity of the sciatic nerve and major blood vessels. Choices C and D, 'Vastus lateralis' and 'Rectus femoris,' are sites commonly used for intramuscular injections but are more suitable for pediatric or specific population groups, not typically for adults.
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