ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A client is prescribed tramadol for pain management. Which of the following should the nurse educate the client about?
- A. It is a non-opioid analgesic
- B. It can cause sedation
- C. It has no risk for dependence
- D. It can be taken as needed
Correct answer: B
Rationale: The correct answer is B. Tramadol can cause sedation, so the nurse should educate the client about this potential side effect. Choice A is incorrect because tramadol is actually an opioid analgesic. Choice C is incorrect as tramadol does carry a risk for dependence, especially with prolonged use. Choice D is not entirely accurate as tramadol is usually prescribed on a scheduled basis rather than as needed.
2. A client who is 38 weeks pregnant with herpes simplex virus is admitted to labor and delivery. What question should the nurse ask?
- A. Do you have any active lesions?
- B. Have your membranes ruptured?
- C. How far apart are your contractions?
- D. Are you positive for beta strep?
Correct answer: A
Rationale: The correct question the nurse should ask the client who is 38 weeks pregnant with herpes simplex virus is 'Do you have any active lesions?' This is crucial because active herpes lesions may necessitate a cesarean delivery to prevent neonatal infection. Choice B, 'Have your membranes ruptured?' is related to assessing for the rupture of membranes, not specific to the client's herpes infection. Choice C, 'How far apart are your contractions?' is related to monitoring labor progress. Choice D, 'Are you positive for beta strep?' is related to group B streptococcus screening, which is important but not the priority in this scenario.
3. A nurse is reviewing the medication class, benzodiazepines. The nurse would use caution when administering benzodiazepines to which of the clients below?
- A. A client with glaucoma
- B. A client with renal failure
- C. A client with hypertension
- D. A client with insomnia
Correct answer: A
Rationale: Benzodiazepines can increase intraocular pressure, which is why they must be used cautiously in patients with glaucoma. In clients with this condition, benzodiazepines can potentially worsen symptoms and lead to further complications involving the eyes. Therefore, administering benzodiazepines to a client with glaucoma should be done with caution. Choices B, C, and D are not directly contraindicated with benzodiazepines, making them less likely to cause harm compared to administering to a client with glaucoma.
4. A nurse is assessing a client 2 hours after a vaginal delivery and notes that the client's uterus is boggy and displaced to the right. Which of the following interventions should the nurse perform first?
- A. Assist the client to void
- B. Massage the uterus
- C. Administer oxytocin
- D. Encourage breastfeeding
Correct answer: A
Rationale: A boggy and displaced uterus is often a sign of bladder distention, which can prevent the uterus from contracting effectively. The priority intervention is to assist the client to void. By emptying the bladder, the uterus can return to midline and become firm. Massaging the uterus or administering oxytocin may be necessary but should come after addressing the bladder distention. Encouraging breastfeeding is important for uterine contraction but is not the priority in this situation.
5. A client has been prescribed phenytoin. Which of the following should the nurse monitor to prevent toxicity?
- A. Blood pressure
- B. Complete blood count
- C. Serum phenytoin levels
- D. Liver function tests
Correct answer: C
Rationale: Corrected Rationale: Serum phenytoin levels should be regularly monitored to prevent toxicity because the therapeutic range is narrow. Monitoring blood pressure (choice A), complete blood count (choice B), and liver function tests (choice D) are not directly related to preventing phenytoin toxicity.
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