ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A client is prescribed metronidazole for a bacterial infection. Which of the following should the nurse teach the client?
- A. Avoid alcohol while taking this medication
- B. It is safe to take during pregnancy
- C. Monitor for increased appetite
- D. It can cause hair loss
Correct answer: A
Rationale: The correct answer is A: 'Avoid alcohol while taking this medication.' Metronidazole can cause a disulfiram-like reaction with alcohol, leading to symptoms like nausea, vomiting, flushing, and headache. Therefore, clients should be instructed to avoid alcohol consumption. Choice B is incorrect because metronidazole is not considered safe during pregnancy, especially in the first trimester. Choice C is incorrect as metronidazole is not known to cause increased appetite. Choice D is also incorrect as hair loss is not a common side effect of metronidazole.
2. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?
- A. Fever
- B. Rash
- C. Fatigue
- D. Increased appetite
Correct answer: B
Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.
3. A nurse is preparing to administer 1 unit of packed RBCs to a client. Which of the following findings should cause the nurse to delay the transfusion?
- A. Blood pressure 140/90 mm Hg
- B. Urine output of 40 mL/hr
- C. Temperature 38.2°C (100.8°F)
- D. Hemoglobin 8 g/dL
Correct answer: C
Rationale: A temperature of 38.2°C (100.8°F) suggests the possibility of an underlying infection or fever, which should be evaluated before proceeding with the transfusion to prevent complications. Elevated temperature can indicate an immune response to incompatible blood components, increasing the risk of a transfusion reaction. The other vital signs and lab results provided are within acceptable ranges for administering packed RBCs, making choices A, B, and D less likely to cause a delay in the transfusion.
4. A nurse is in the emergency department monitoring the hydration status of a client receiving oral rehydration. What should the nurse intervene for?
- A. Heart rate 120/min
- B. Urine output 30 mL/hour
- C. Blood pressure 110/70 mmHg
- D. Skin turgor is normal
Correct answer: A
Rationale: A heart rate of 120/min may indicate dehydration or inadequate hydration, prompting the need for IV fluid replacement. Elevated heart rate is a sensitive indicator of dehydration as the body attempts to maintain cardiac output. Urine output of 30 mL/hour is within the normal range (30 mL/hour is the minimum acceptable urine output for an adult). Blood pressure of 110/70 mmHg is within the normal range. Normal skin turgor is a positive sign indicating adequate hydration.
5. A nurse is caring for a client who has a deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to ambulate frequently.
- B. Apply warm, moist compresses to the affected leg.
- C. Massage the affected leg.
- D. Place the client in a supine position.
Correct answer: B
Rationale: The correct intervention for a client with deep vein thrombosis (DVT) is to apply warm, moist compresses to the affected leg. This helps alleviate pain and improve circulation in the affected area, aiding in the treatment of DVT. Encouraging the client to ambulate frequently (Choice A) is contraindicated as it can dislodge the clot and lead to complications. Massaging the affected leg (Choice C) is also contraindicated as it can dislodge the clot and potentially cause an embolism. Placing the client in a supine position (Choice D) is not specifically indicated for DVT treatment; elevation of the affected leg is preferred over placing the client completely supine.
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