ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A healthcare professional is assessing a client for signs of stroke. Which of the following should the healthcare professional look for?
- A. Slurred speech
- B. Increased appetite
- C. Elevated heart rate
- D. Hyperactivity
Correct answer: A
Rationale: Corrected Question: A healthcare professional is assessing a client for signs of stroke. Slurred speech is a common sign of stroke and should be assessed immediately. Choices B, C, and D are incorrect because increased appetite, elevated heart rate, and hyperactivity are not typical signs of a stroke.
2. A nurse is assessing a client with a history of heart failure. Which of the following findings should the nurse monitor?
- A. Increased energy
- B. Peripheral edema
- C. Elevated heart rate
- D. Improved lung sounds
Correct answer: B
Rationale: The correct answer is B: Peripheral edema. In heart failure, the heart's inability to pump effectively can lead to fluid backup, causing swelling in the extremities, known as peripheral edema. Monitoring for peripheral edema is crucial as it is a common sign of worsening heart failure. Choices A, C, and D are incorrect because increased energy, elevated heart rate, and improved lung sounds are not typical findings in heart failure. Increased energy is not usually associated with heart failure, an elevated heart rate may occur as a compensatory mechanism but is not a direct sign of heart failure, and improved lung sounds are not expected in heart failure which often presents with crackles or wheezes due to pulmonary congestion.
3. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate. Which of the following is an indication of magnesium toxicity?
- A. Blood glucose of 160 mg/dL
- B. Urine output of 20 mL/hour
- C. Systolic BP of 140 mm Hg
- D. Respiratory rate of 20/min
Correct answer: B
Rationale: The correct answer is B: Urine output of 20 mL/hour. Urine output below 30 mL/hour is a sign of magnesium toxicity due to the risk of accumulation in the body. Choices A, C, and D are not indicative of magnesium toxicity. Elevated blood glucose, systolic blood pressure, and normal respiratory rate are not specific signs of magnesium toxicity.
4. A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?
- A. Teach the client to report findings of IV extravasation
- B. Evaluate the patency of the IV
- C. Consult with the pharmacist about the prescription
- D. Verify the prescription with the provider
Correct answer: D
Rationale: The priority action is to verify the prescription with the provider. Verifying the prescription ensures patient safety by preventing fluid volume overload and dysrhythmias, which can result from infusing potassium too rapidly. Teaching the client about IV extravasation, evaluating IV patency, and consulting with the pharmacist are important but should come after verifying the prescription to ensure the ordered treatment is appropriate and safe for the client's condition.
5. A client is preparing advance directives. Which of the following statements by the client indicates an understanding of advance directives?
- A. I cannot change my instructions once they are made
- B. My doctor will need to approve my advance directives
- C. I need an attorney to witness my signature on the advance directives
- D. I have the right to refuse treatment
Correct answer: D
Rationale: The correct answer is D: 'I have the right to refuse treatment.' This statement indicates an understanding of advance directives because advance directives allow individuals to express their treatment preferences, including the right to refuse treatment if they choose to do so. Choice A is incorrect because individuals can update or change their advance directives as needed. Choice B is incorrect because advance directives are based on the individual's preferences, not the doctor's approval. Choice C is incorrect as witnessing an advance directive typically requires a witness who is not an attorney, depending on the state's specific requirements.
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