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 who has DVT. Which of the following instructions should the nurse include in the plan of care?
- A. Limit the client’s fluid intake to 1500 mL per day
- B. Massage the affected extremity to relieve pain
- C. Apply cold packs to the affected extremity
- D. Elevate the client’s affected extremity when in bed
Correct answer: D
Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.
3. A nurse is providing teaching about the Mediterranean diet to a client who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching?
- A. I will limit my intake of red meat to twice monthly.
- B. I can have dairy in moderate portions daily.
- C. I can have fish two times a week.
- D. I can drink wine in moderation.
Correct answer: A
Rationale: The correct answer is A. In the Mediterranean diet, red meat should be limited to two times monthly, not weekly. Choice B is correct as dairy in moderate portions daily is suitable for the Mediterranean diet. Choice C is also correct as having fish two times a week aligns with the Mediterranean diet. Choice D is correct as moderate wine consumption is a component of the Mediterranean diet.
4. A client has been prescribed enoxaparin. Which of the following instructions should the nurse provide regarding self-administration?
- A. Pinch the skin and inject at a 45-degree angle
- B. Massage the injection site after administering
- C. Administer at a 90-degree angle
- D. Avoid rotating injection sites
Correct answer: A
Rationale: The correct answer is to pinch the skin and inject at a 45-degree angle when administering enoxaparin. This technique helps ensure proper administration of the medication. Massaging the injection site after administering is unnecessary and could increase the risk of bleeding. Administering at a 90-degree angle is not recommended for enoxaparin injections. Rotating injection sites is important to prevent tissue damage and irritation.
5. A nurse is assessing a client for signs of anemia. Which of the following findings should the nurse look for?
- A. Increased energy
- B. Pale skin
- C. Elevated blood pressure
- D. Weight gain
Correct answer: B
Rationale: The correct answer is B: 'Pale skin.' Pale skin is a common sign of anemia due to reduced hemoglobin levels, which affects the skin color. Anemia is characterized by a decrease in the number of red blood cells or hemoglobin in the blood, leading to a paler complexion. Choices A, C, and D are incorrect. 'Increased energy' is not typically associated with anemia, as fatigue is a common symptom. 'Elevated blood pressure' is not a typical finding in anemia; instead, anemia may cause hypotension. 'Weight gain' is not a direct symptom of anemia; in fact, weight loss may occur in some cases due to reduced appetite or other factors associated with anemia.
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