ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A healthcare professional is assessing a client for potential complications after surgery. Which of the following should the healthcare professional monitor for?
- A. Decreased urine output
- B. Increased appetite
- C. Improved mobility
- D. Normal temperature
Correct answer: A
Rationale: Corrected Rationale: Decreased urine output can indicate renal complications or dehydration, which are common post-surgical complications. Monitoring urine output is crucial for detecting early signs of kidney dysfunction or fluid imbalances. Increased appetite, improved mobility, and normal temperature are not typical signs of immediate post-surgical complications and would not be the priority for monitoring in this case.
2. A nurse is teaching postoperative care to the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching?
- A. Provide an orthodontic pacifier for comfort
- B. Offer fluids using a straw
- C. Cleanse the suture line with a cotton-tip swab
- D. Remove elbow splints periodically to perform range of motion
Correct answer: D
Rationale: The correct answer is D. Elbow splints are utilized to prevent the child from touching the surgical site. However, it is essential to remove them periodically to conduct range-of-motion exercises to prevent joint stiffness. Choices A, B, and C are incorrect because providing an orthodontic pacifier, offering fluids using a straw, and cleansing the suture line with a cotton-tip swab are not directly related to postoperative care following a cleft palate repair.
3. When teaching a client about the use of lisinopril, which of the following should be included?
- A. It can cause a persistent cough
- B. It is a calcium channel blocker
- C. It is safe during pregnancy
- D. It should be taken with food
Correct answer: A
Rationale: The correct answer is A. Lisinopril is an ACE inhibitor, and a common side effect associated with its use is a persistent cough. This is important information that the client should be aware of. Choice B is incorrect because lisinopril is not a calcium channel blocker, it is an ACE inhibitor. Choice C is incorrect as lisinopril is not considered safe during pregnancy, especially during the second and third trimesters as it can cause harm to the fetus. Choice D is incorrect because lisinopril is typically recommended to be taken on an empty stomach, about an hour before meals.
4. A nurse is preparing to administer enoxaparin to a client. Which of the following actions should the nurse take?
- A. Aspirate before injecting
- B. Massage the site after injecting
- C. Administer the injection in the abdomen
- D. Inject at a 90-degree angle
Correct answer: C
Rationale: The correct action the nurse should take when administering enoxaparin is to inject the medication in the abdomen subcutaneously. This route ensures proper absorption of the medication. Aspiration is not necessary before injecting enoxaparin as it is a subcutaneous injection, not an intramuscular injection. Massaging the site after injecting should be avoided to prevent bruising. Enoxaparin injections are typically given at a 45 to 90-degree angle, not necessarily at a strict 90-degree angle.
5. A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?
- A. Place the infant under a radiant warmer
- B. Move the probe site every 3 hours
- C. Heat the skin one minute prior to placing the probe
- D. Place the sensor on the index finger
Correct answer: B
Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures more accurate monitoring of oxygen saturation. Placing the infant under a radiant warmer (choice A) is unnecessary and not related to pulse oximetry. Heating the skin before placing the probe (choice C) can lead to burns and is not recommended. Placing the sensor on the index finger (choice D) is not appropriate for continuous monitoring in infants.
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