ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?
- A. Fever
- B. Rash
- C. Fatigue
- D. Increased appetite
Correct answer: B
Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.
2. 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.
3. A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?
- A. Lower back pain
- B. Shortness of breath
- C. Decreased fetal movement
- D. Nausea and vomiting
Correct answer: A
Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery. Shortness of breath (Choice B), decreased fetal movement (Choice C), and nausea and vomiting (Choice D) can be common during pregnancy but are not typically associated with preterm labor. While they should be monitored, they are not immediate signs of concern for preterm labor.
4. A client is experiencing suicidal thoughts and states, 'Why not end my misery?' What is the best response by the nurse?
- A. Why do you think your life isn’t worth living anymore?
- B. Do you have a plan to end your life?
- C. I need to understand what you mean by misery.
- D. You can trust me to share your thoughts.
Correct answer: B
Rationale: The correct answer is B: 'Do you have a plan to end your life?' When a client expresses suicidal thoughts, it is crucial to assess the immediate risk. Inquiring about a specific plan can help determine the seriousness of the situation. Choice A is less direct and may not provide a clear indication of the immediate risk. Choice C focuses on the interpretation of 'misery' rather than assessing the risk of suicide. Choice D offers support but does not address the critical assessment of the client's immediate safety.
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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