ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A healthcare professional is assessing a client with heart failure. Which of the following signs should the healthcare professional monitor for?
- A. Peripheral edema
- B. Tachycardia
- C. Bradycardia
- D. Hypotension
Correct answer: A
Rationale: In heart failure, the accumulation of fluid can lead to peripheral edema, which is swelling in the extremities. This is a common sign that healthcare professionals should monitor for. While tachycardia (increased heart rate), bradycardia (decreased heart rate), and hypotension (low blood pressure) can also occur in heart failure, they are not the primary signs typically associated with this condition. Therefore, peripheral edema is the most relevant sign to monitor in this case.
2. A nurse is caring for a client prescribed levetiracetam. Which of the following should the nurse monitor?
- A. Liver function
- B. Blood glucose levels
- C. Serum creatinine
- D. Blood pressure
Correct answer: C
Rationale: The correct answer is C: Serum creatinine. Levetiracetam requires monitoring of renal function, specifically serum creatinine levels, as it is primarily eliminated by the kidneys. Monitoring liver function (Choice A) is not necessary for levetiracetam. Blood glucose levels (Choice B) are typically not affected by levetiracetam. While monitoring blood pressure (Choice D) is important in general patient care, it is not specifically required for clients prescribed levetiracetam.
3. A nurse enters a client’s room and sees smoke coming from the trash can. Which action should the nurse take first?
- A. Extinguish the fire
- B. Activate the fire alarm
- C. Evacuate the room
- D. Call the client’s family
Correct answer: C
Rationale: In a fire emergency, the priority for the nurse is to ensure safety. The correct first action is to evacuate the room, following the RACE protocol, which stands for Rescue, Alarm, Contain, and Extinguish/Evacuate. Activating the fire alarm alerts others, extinguishing the fire can escalate the situation if not done correctly, and calling the client's family is not a priority in this emergency scenario.
4. A nurse is planning care for an adolescent client with chronic renal failure. Which action should the nurse include?
- A. Encourage a diet high in calcium
- B. Provide a diet high in potassium
- C. Ensure increased fluid intake
- D. Restrict protein intake to the RDA
Correct answer: D
Rationale: In chronic renal failure, it is essential to restrict protein intake to the Recommended Dietary Allowance (RDA) to reduce the accumulation of waste products that the kidneys can no longer effectively eliminate. Choices A, B, and C are incorrect because in chronic renal failure, high calcium, high potassium, and increased fluid intake can further strain the kidneys and worsen the condition.
5. A client is newly diagnosed with hypothyroidism and prescribed levothyroxine. Which of the following instructions should the nurse include?
- A. Take the medication with food.
- B. Take the medication in the evening.
- C. Take the medication on an empty stomach.
- D. Take the medication only when experiencing symptoms.
Correct answer: C
Rationale: The correct instruction is to take levothyroxine on an empty stomach. This is necessary for proper absorption and effectiveness of the medication. Taking it with food can interfere with absorption. Timing is also crucial; it is usually recommended to take levothyroxine in the morning to prevent potential interactions with food and other medications throughout the day. Taking the medication in the evening may lead to sleep disturbances. Lastly, waiting to take the medication only when symptoms occur is not appropriate as levothyroxine is typically taken regularly to maintain thyroid hormone levels within the body.
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