ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A healthcare professional is assessing a client with deep vein thrombosis (DVT). Which of the following interventions should the healthcare professional include in the plan of care?
- A. Apply ice packs to the affected extremity.
- B. Encourage ambulation every hour.
- C. Elevate the affected leg when in bed.
- D. Massage the affected area to improve circulation.
Correct answer: C
Rationale: Elevating the affected leg is a crucial intervention in the care of a client with deep vein thrombosis (DVT). This position helps reduce swelling and promotes venous return, which can alleviate symptoms associated with DVT. Applying ice packs (Choice A) may worsen the condition by causing vasoconstriction. Encouraging ambulation (Choice B) can dislodge the clot and lead to fatal complications. Massaging the affected area (Choice D) can also dislodge the clot and is contraindicated in DVT.
2. A nurse is caring for a client prescribed clopidogrel. Which of the following should the nurse monitor?
- A. Liver function tests
- B. Blood pressure
- C. Potassium levels
- D. Respiratory rate
Correct answer: A
Rationale: Corrected Rationale: Clopidogrel is an antiplatelet medication, so the nurse should monitor for signs of bleeding and liver function tests due to potential liver effects. Monitoring liver function tests is essential to detect any adverse effects on the liver because clopidogrel can cause hepatotoxicity. While monitoring blood pressure, potassium levels, and respiratory rate are important in general patient care, they are not the priority assessments specifically related to clopidogrel use.
3. Following delivery, the nurse places the newborn under a radiant heat warmer. Which of the following is this action used to prevent?
- A. Cold stress
- B. Hyperthermia
- C. Dehydration
- D. Hypoxia
Correct answer: A
Rationale: Placing the newborn under a radiant heat warmer is used to prevent cold stress. Cold stress in newborns can lead to increased oxygen consumption and energy expenditure as the body tries to maintain its temperature, potentially resulting in hypoglycemia and metabolic acidosis if not addressed. The radiant warmer helps maintain the infant's body temperature, reducing the risk of cold stress and its complications. Choices B, C, and D are incorrect because the primary purpose of using a radiant warmer in this scenario is to prevent cold stress specifically, not hyperthermia, dehydration, or hypoxia.
4. A nurse is caring for a client who is postpartum, has a deep-vein thrombosis, and is receiving heparin therapy via subcutaneous injections. Which of the following actions should the nurse take?
- A. Request a prescription for PRN aspirin from the provider.
- B. Massage the injection site thoroughly following administration.
- C. Instruct the client that they cannot breastfeed while receiving heparin.
- D. Administer the injection in the client's abdomen.
Correct answer: D
Rationale: The nurse should administer the injection in the abdomen, as this is a common site for subcutaneous heparin administration. Massaging the injection site can lead to bruising or discomfort and should be avoided. Instructing the client not to breastfeed while on heparin is inaccurate, as heparin does not pass into breast milk in significant amounts. Aspirin is contraindicated for clients on heparin due to the increased risk of bleeding, so requesting a prescription for PRN aspirin would not be appropriate in this situation.
5. A nurse is preparing a client for a colonoscopy. Which of the following medications should the nurse anticipate the provider to prescribe as an anesthetic for the procedure?
- A. Propofol
- B. Pancuronium
- C. Promethazine
- D. Pentoxifylline
Correct answer: A
Rationale: The correct answer is A, Propofol. Propofol is a short-acting anesthetic medication commonly used to induce moderate sedation for procedures like a colonoscopy. This medication provides rapid onset and recovery, making it an ideal choice for such procedures. Choice B, Pancuronium, is a neuromuscular blocking agent used for muscle relaxation during surgery and would not be appropriate for sedation during a colonoscopy. Choice C, Promethazine, is an antihistamine used for nausea and motion sickness, not for anesthesia. Choice D, Pentoxifylline, is a medication used to improve blood flow in patients with circulation problems and is not indicated for anesthesia during a colonoscopy.
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