ATI LPN
PN ATI Capstone Maternal Newborn
1. A newborn demonstrates respiratory distress, and routine suctioning with the bulb syringe is unsuccessful. What is the next nursing intervention?
- A. Initiate chest compressions
- B. Administer oxygen
- C. Suction with a mechanical device
- D. Notify the healthcare provider
Correct answer: C
Rationale: When routine suctioning with a bulb syringe is unsuccessful in a newborn demonstrating respiratory distress, the next appropriate nursing intervention is to suction with a mechanical device. This method ensures effective removal of any airway obstruction. Initiating chest compressions (Choice A) is not indicated in this scenario as the primary concern is airway clearance. Administering oxygen (Choice B) may be necessary, but addressing the airway obstruction should take precedence. Notifying the healthcare provider (Choice D) can be considered after attempting mechanical suction if the newborn's condition does not improve.
2. A healthcare provider is providing education on the use of clozapine. Which of the following should be included?
- A. Monitor for agranulocytosis
- B. It is a first-line treatment
- C. It can cause significant weight loss
- D. It has no risk for metabolic syndrome
Correct answer: A
Rationale: Correct Answer: A nurse should include monitoring for agranulocytosis when educating a patient about clozapine. Clozapine is known to cause agranulocytosis, a potentially life-threatening decrease in white blood cells. This adverse effect requires close monitoring to detect it early. Choices B, C, and D are incorrect because clozapine is not a first-line treatment for most conditions, it is more commonly associated with weight gain rather than weight loss, and it is known to have a risk for metabolic syndrome.
3. A healthcare professional is preparing to administer morphine for severe pain. What is the priority assessment the professional should make before administration?
- A. Blood pressure
- B. Respiratory rate
- C. Heart rate
- D. Temperature
Correct answer: B
Rationale: Before administering morphine, the priority assessment the healthcare professional should make is the client's respiratory rate. Morphine can cause respiratory depression, so assessing the respiratory rate is crucial to prevent any potential complications. Assessing blood pressure, heart rate, and temperature are important as well, but they are not the priority when administering morphine for severe pain.
4. A nurse is teaching a client who is taking prednisone about the adverse effects of this medication. Which of the following should the nurse emphasize?
- A. Weight gain
- B. Insomnia
- C. Hyperglycemia
- D. Hypertension
Correct answer: C
Rationale: The correct adverse effect of prednisone that the nurse should emphasize is hyperglycemia. Prednisone is known to increase blood sugar levels, leading to hyperglycemia. While weight gain and other metabolic changes are possible side effects, hyperglycemia is a more critical concern due to the risk of uncontrolled blood sugar levels and its impact on overall health. Insomnia and hypertension are not typically associated with prednisone use, making them less relevant to emphasize during client education.
5. A client is found on the floor of their room experiencing a seizure. Which of the following actions is the priority for the nurse?
- A. Place the client on their side with their head forward
- B. Call for help
- C. Protect the client's head
- D. Restrain the client
Correct answer: A
Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration, which is crucial in managing the client's safety during a seizure. Calling for help is important but ensuring the client's immediate safety by positioning them correctly takes precedence. Protecting the client's head can be done concurrently while positioning the client. Restraint is not appropriate during a seizure as it can lead to injuries and complications.
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