ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A healthcare professional is assessing a client for signs of infection. Which of the following findings should the healthcare professional look for?
- A. Increased energy
- B. Fever
- C. Improved appetite
- D. Stable weight
Correct answer: B
Rationale: Corrected Question: A healthcare professional is assessing a client for signs of infection. The correct answer is 'Fever.' Fever is a common sign of infection and indicates an immune response to an invading pathogen. Increased energy (Choice A) is not typically associated with infection, as the body often feels fatigued when fighting an infection. Improved appetite (Choice C) and stable weight (Choice D) are not specific signs of infection and may not necessarily indicate the presence of an infectious process. Therefore, the healthcare professional should focus on monitoring for fever as a key indicator of infection.
2. A nurse is caring for a client in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate?
- A. Decrease intake of vitamins and supplements to every other day
- B. Eat 15 g of fiber per day
- C. Consume 48 ounces of water each day
- D. Drink hot water with lemon juice each morning
Correct answer: D
Rationale: The correct answer is D. Drinking hot water with lemon juice in the morning is a natural and safe way to stimulate bowel movements and relieve constipation during pregnancy. Option A is incorrect as vitamins and supplements should not be decreased without consulting a healthcare provider, especially during pregnancy. Option B is inadequate as the recommended daily fiber intake during pregnancy is higher than 15g. Option C, while important for overall health, does not directly address constipation relief in pregnancy.
3. A client is receiving digoxin therapy. Which of the following should the nurse monitor?
- A. Liver function
- B. Serum electrolytes
- C. Blood pressure
- D. All of the above
Correct answer: D
Rationale: When a client is receiving digoxin therapy, it is crucial for the nurse to monitor liver function, serum electrolytes (especially potassium levels), and blood pressure. Digoxin is known to affect the heart's electrical activity and can lead to toxic effects if not managed properly. Monitoring liver function helps to assess the drug's metabolism and excretion. Checking serum electrolytes, especially potassium, is essential because digoxin toxicity can be exacerbated by electrolyte imbalances, particularly hypokalemia. Monitoring blood pressure is necessary because digoxin can influence cardiac contractility and heart rate, potentially affecting blood pressure. Therefore, monitoring all these parameters is vital to ensure the client's safety and therapeutic effectiveness of digoxin. Choices A, B, and C are incorrect because monitoring only one or two of these parameters may not provide a comprehensive assessment of the client's response to digoxin therapy.
4. A nurse is caring for a client with a new prescription for atorvastatin. Which of the following should the nurse monitor?
- A. Liver function tests
- B. Potassium levels
- C. Blood glucose levels
- D. Serum calcium levels
Correct answer: A
Rationale: The correct answer is A: Liver function tests. Atorvastatin, a medication commonly used to lower cholesterol levels, can potentially cause liver damage as a side effect. Monitoring liver function tests is essential to detect any abnormalities early. Choices B, C, and D are incorrect because atorvastatin is not known to directly impact potassium levels, blood glucose levels, or serum calcium levels. While these parameters may be monitored for other reasons, the priority when administering atorvastatin is to monitor liver function due to the risk of hepatotoxicity.
5. A nurse is caring for a client in active labor who is receiving oxytocin. The nurse notes that the client is experiencing contractions every 1 minute lasting 90 seconds. Which of the following actions should the nurse take?
- A. Stop the oxytocin infusion
- B. Administer oxygen
- C. Increase the IV fluid rate
- D. Prepare for delivery
Correct answer: A
Rationale: The correct action the nurse should take in this situation is to stop the oxytocin infusion. Contractions occurring every 1 minute lasting 90 seconds indicate uterine hyperstimulation, which can lead to fetal distress by compromising oxygen supply. Stopping the oxytocin infusion will help reduce the frequency and intensity of contractions, allowing for better fetal oxygenation. Administering oxygen (Choice B) may be necessary if there are signs of fetal distress, but stopping the oxytocin is the priority. Increasing IV fluid rate (Choice C) is not the appropriate action in response to hyperstimulation. While preparing for delivery (Choice D) may eventually be necessary, the immediate action should be to address the hyperstimulation by stopping the oxytocin infusion.
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