a nurse in the emergency department is caring for a patient who has extensive partial and full thickness burns of the head neck and chest while planni
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A nurse in the emergency department is caring for a patient who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the patient’s care, the nurse should identify which of the following risks as the priority for assessment and intervention?

Correct answer: B

Rationale: When a patient has extensive burns involving the head, neck, and chest, the priority concern is airway obstruction. The proximity of the burns to the airway can lead to swelling and compromise the patient's ability to breathe. In this situation, ensuring a clear airway and adequate oxygenation takes precedence over other risks such as infection, fluid imbalance, or pain management. While these are also important considerations in burn care, the immediate threat to the patient's life from airway compromise makes it the priority for assessment and intervention.

2. A client receiving opiates for pain management was initially sedated but is no longer sedated after three days. What action should the nurse take?

Correct answer: C

Rationale: The correct answer is C: No action is needed at this time. Sedation from opiates commonly decreases as the body adjusts to the medication. It is a positive sign that the sedation has resolved, indicating the client is tolerating the current dosage well. Initiating additional non-pharmacological pain management techniques (Choice A) is unnecessary since the current pain management regimen is effective. Notifying the provider for a dosage adjustment (Choice B) is premature and not indicated when the sedation has resolved. Contacting the provider to request an alternate method of pain management (Choice D) is excessive and not warranted in this situation where the client is no longer sedated and the current pain management plan is effective.

3. A client with cholecystitis has been prescribed a low-fat diet. Which of the following meal selections by the client indicates understanding of the education?

Correct answer: D

Rationale: The correct answer is D. Roast turkey is a lean protein option suitable for a low-fat diet. Rice pilaf and green beans are also low in fat. Choices A, B, and C contain high-fat ingredients like gravy, cheese, cream, and ice cream, which are not suitable for a low-fat diet.

4. A client is being taught about the use of levothyroxine. Which of the following should be included in the teaching?

Correct answer: B

Rationale: The correct answer is B: 'Take it at the same time every day.' It is important to take levothyroxine consistently at the same time each day to maintain stable thyroid hormone levels. Choice A is incorrect as levothyroxine should be taken on an empty stomach for better absorption. Choice C is incorrect because stopping levothyroxine suddenly can lead to adverse effects due to sudden changes in hormone levels. Choice D is also incorrect as hyperglycemia is not a common side effect associated with levothyroxine.

5. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?

Correct answer: A

Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.

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