ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. While assessing four clients, which client data should be reported to the provider?
- A. Client with pleurisy who reports a pain level of 6 out of 10 when coughing
- B. Client with 110 mL of serosanguineous fluid from a JP drain
- C. Client 4 hours postoperative with a heart rate of 98 bpm
- D. Client undergoing chemotherapy with an absolute neutrophil count of 75/mm³
Correct answer: D
Rationale: An absolute neutrophil count of 75/mm³ is critically low and places the client at high risk for infection, necessitating immediate intervention. Neutropenia increases susceptibility to infections, making it essential to report this finding promptly. The other options, such as pain level in pleurisy, drainage amount from a drain, and heart rate postoperatively, are important but do not indicate an immediate life-threatening condition that requires urgent provider notification.
2. A client is prescribed omeprazole. Which of the following should the nurse monitor?
- A. Liver function
- B. Magnesium levels
- C. Blood glucose
- D. Hemoglobin levels
Correct answer: B
Rationale: Corrected Rationale: Omeprazole can cause hypomagnesemia, a condition characterized by low magnesium levels in the blood. Monitoring magnesium levels is crucial to detect and address this potential adverse effect. Liver function (Choice A) is not typically affected by omeprazole. Blood glucose (Choice C) and hemoglobin levels (Choice D) are not directly impacted by omeprazole administration. Therefore, magnesium levels (Choice B) are the most appropriate parameter to monitor in a client prescribed omeprazole.
3. A client with HIV and neutropenia requires specific care from the nurse. Which of the following precautions should the nurse take while caring for this client?
- A. Wear an N95 respirator while caring for the client.
- B. Use a dedicated stethoscope for the client.
- C. Insert an indwelling urinary catheter to monitor urinary output.
- D. Monitor the client’s vital signs every 8 hours.
Correct answer: B
Rationale: Using dedicated equipment for a neutropenic client, such as a stethoscope, helps prevent infections. Neutropenic clients have a weakened immune system, making them vulnerable to infections from common pathogens. Wearing an N95 respirator is not necessary unless airborne precautions are required. Inserting a urinary catheter should be avoided unless necessary to prevent introducing pathogens. Monitoring vital signs should be done more frequently, typically every 4 hours, to promptly identify any changes in the client's condition.
4. A nurse is teaching a client who is taking prednisone about the adverse effects of this medication. Which of the following should the nurse emphasize?
- A. Weight gain
- B. Insomnia
- C. Hyperglycemia
- D. Hypertension
Correct answer: C
Rationale: The correct adverse effect of prednisone that the nurse should emphasize is hyperglycemia. Prednisone is known to increase blood sugar levels, leading to hyperglycemia. While weight gain and other metabolic changes are possible side effects, hyperglycemia is a more critical concern due to the risk of uncontrolled blood sugar levels and its impact on overall health. Insomnia and hypertension are not typically associated with prednisone use, making them less relevant to emphasize during client education.
5. During a skin assessment on a client with risk factors for skin cancer, a nurse should understand that a suspicious lesion is:
- A. Scaly and red
- B. Asymmetric with variegated coloring
- C. Firm and rubbery
- D. Brown with a wart-like texture
Correct answer: B
Rationale: The correct answer is B: Asymmetric with variegated coloring. An asymmetric lesion with variegated coloring, meaning different shades of color within the same lesion, is characteristic of melanoma, a type of skin cancer. This type of lesion should raise suspicions and prompt further evaluation. Choices A, C, and D do not typically represent characteristics of suspicious skin lesions associated with skin cancer. Lesions that are scaly and red (Choice A) may indicate other skin conditions like eczema or psoriasis. Firm and rubbery lesions (Choice C) are more suggestive of benign skin growths like dermatofibromas. Lesions that are brown with a wart-like texture (Choice D) are often indicative of seborrheic keratosis, a benign growth, rather than a suspicious lesion related to skin cancer.
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