ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A community health nurse is teaching a group of clients about first aid for wounds. Which client statement indicates understanding?
- A. Remove blood-saturated dressings
- B. Apply clean dressings over the saturated ones and hold pressure
- C. Elevate the wound above heart level
- D. Leave the wound open to air
Correct answer: B
Rationale: The correct answer is B. Applying clean dressings over blood-saturated ones and holding pressure helps to control bleeding and prevent tissue disruption. Removing blood-saturated dressings can cause further damage by disrupting the forming clot. Elevating the wound above heart level is beneficial to reduce swelling, but it is not the best immediate action for a blood-saturated dressing. Leaving the wound open to air can increase the risk of infection and slow down the healing process.
2. A nurse is caring for a client who is experiencing preterm labor and has a new prescription for terbutaline. Which of the following findings is a contraindication for the administration of this medication?
- A. Heart disease
- B. Cervical dilation of 2 cm
- C. Gestational age of 34 weeks
- D. Allergy to penicillin
Correct answer: A
Rationale: The correct answer is A, heart disease. Terbutaline is contraindicated in clients with heart disease because it can lead to tachycardia and other cardiac complications due to its beta-agonist properties. Choice B, cervical dilation of 2 cm, is not a contraindication for terbutaline administration in preterm labor. Choice C, gestational age of 34 weeks, does not contraindicate the use of terbutaline for preterm labor. Choice D, allergy to penicillin, is not related to the contraindications of terbutaline.
3. A nurse is caring for a newborn who is 1 hour old and has a respiratory rate of 50 breaths per minute with periods of apnea lasting up to 10 seconds. Which of the following actions should the nurse take?
- A. Administer oxygen
- B. Stimulate the newborn
- C. Initiate positive pressure ventilation
- D. Continue routine monitoring
Correct answer: D
Rationale: A respiratory rate of 50 breaths per minute with occasional periods of apnea lasting less than 15 seconds is normal for a newborn. The nurse should continue routine monitoring unless the apneic periods become prolonged or the newborn shows signs of respiratory distress. Administering oxygen or initiating positive pressure ventilation is not indicated in this scenario as the newborn's respiratory rate and apneic episodes are within normal limits for their age. Stimulating the newborn is also unnecessary since the described parameters fall within the expected range for a 1-hour-old infant.
4. A healthcare professional is preparing to administer heparin 8,000 units subcutaneously every eight hrs. The amount available is heparin injection 10,000 units/mL. How many milliliters should the healthcare professional administer per dose?
- A. 0.7 mL
- B. 0.8 mL
- C. 1.0 mL
- D. 1.2 mL
Correct answer: B
Rationale: Calculation: 8000 units / 10,000 units per mL = 0.8 mL. To correctly administer the prescribed dose of 8000 units, the healthcare professional should draw up 0.8 mL from the 10,000 units/mL vial. Options A, C, and D are incorrect as they do not accurately reflect the calculation based on the available concentration of heparin.
5. A nurse is caring for a client who is postoperative following a thyroidectomy. The client reports tingling in the fingers and around the mouth. The nurse should anticipate which of the following interventions?
- A. Administer calcium gluconate
- B. Provide a high-protein diet
- C. Administer levothyroxine
- D. Apply a warm compress to the client's neck
Correct answer: A
Rationale: Tingling in the fingers and around the mouth is a sign of hypocalcemia, which can occur after thyroid surgery due to accidental damage to the parathyroid glands. Hypocalcemia is common after thyroidectomy due to potential parathyroid damage. Calcium gluconate is the appropriate intervention to treat hypocalcemia. Providing a high-protein diet or administering levothyroxine are not indicated for hypocalcemia. Applying a warm compress to the client's neck would not address the underlying issue of hypocalcemia.
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