ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A healthcare professional is assessing a client for signs of hyperglycemia. Which of the following findings should the healthcare professional look for?
- A. Increased thirst
- B. Weight gain
- C. Decreased urination
- D. Fatigue
Correct answer: A
Rationale: Increased thirst is a classic symptom of hyperglycemia due to the body trying to eliminate excess glucose through urine, leading to dehydration and increased thirst. Weight gain, decreased urination, and fatigue are not typical signs of hyperglycemia. Weight gain is more commonly associated with conditions like hypothyroidism or fluid retention. Decreased urination is not a typical symptom of hyperglycemia, as high blood sugar levels usually lead to increased urination. Fatigue can be a symptom of hyperglycemia, but it is not as specific or characteristic as increased thirst.
2. A nurse is preparing to assist a provider with the insertion of a nontunneled percutaneous central venous catheter into a client’s subclavian vein. Which of the following actions should the nurse take?
- A. Position the client in a high-Fowler’s position
- B. Place the client in Trendelenburg position
- C. Place a rolled towel under the client’s neck
- D. Assist the client into a side-lying position
Correct answer: B
Rationale: The correct action for the nurse to take when assisting with the insertion of a nontunneled percutaneous central venous catheter into the subclavian vein is to place the client in Trendelenburg position. This position helps distend the veins and reduces the risk of air embolism during the insertion procedure. Option A, positioning the client in a high-Fowler’s position, would not be appropriate as it does not facilitate venous distention. Option C, placing a rolled towel under the client’s neck, is not directly related to the procedure and does not serve a specific purpose in this context. Option D, assisting the client into a side-lying position, is also not the correct choice as Trendelenburg position is preferred for this procedure to aid in vein distention.
3. When caring for a client with a sealed radiation implant, which action should be included in the plan of care?
- A. Remove dirty linens after double bagging them
- B. Wear a dosimeter film badge while in the client’s room
- C. Limit visitors to 1 hour per day
- D. Ensure family members remain at least 3 feet from the client
Correct answer: B
Rationale: The correct answer is to wear a dosimeter film badge while in the client's room. This is crucial for monitoring radiation exposure levels when caring for a client with a sealed radiation implant. Option A is incorrect as removing dirty linens after double bagging them is not directly related to radiation safety. Option C is incorrect as there is no specific guideline to limit visitors to 1 hour per day for clients with sealed radiation implants. Option D is incorrect as the distance of family members from the client is not a primary safety measure when dealing with sealed radiation implants.
4. A healthcare professional is completing a nutritional assessment on a client and measures body mass index (BMI). Which of the following readings correlates with a BMI of an overweight client?
- A. 18.5
- B. 24.9
- C. 25
- D. 32
Correct answer: C
Rationale: A BMI of 25-29.9 is considered overweight. Therefore, a BMI of 25 correlates with an overweight client. A BMI of 18.5-24.9 indicates a healthy weight. Choices A, B, and D are incorrect as they fall into the healthy weight or obese categories, not overweight.
5. A nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to an adult client. Which of the following is a contraindication to this vaccine?
- A. The possibility of pregnancy within 4 weeks
- B. Client allergy to strawberry
- C. Client history of genital herpes
- D. The possibility of overseas travel in the next month
Correct answer: A
Rationale: The correct answer is A. The MMR vaccine is contraindicated in pregnant women due to the risk of fetal harm. It is recommended that women avoid becoming pregnant for at least 4 weeks after receiving the vaccine. Choice B, client allergy to strawberry, is not a contraindication for the MMR vaccine. Choice C, client history of genital herpes, is not a contraindication for the MMR vaccine. Choice D, the possibility of overseas travel in the next month, is not a contraindication for the MMR vaccine.
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