ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a 7-month-old infant being treated for severe dehydration. Which finding indicates treatment has been effective?
- A. Skin turgor displays tenting
- B. Flat anterior fontanel
- C. Cool, mottled skin
- D. Hyperpnea
Correct answer: B
Rationale: A flat anterior fontanel indicates improved hydration in infants, as dehydration typically causes sunken fontanels.
2. A client has a new prescription for metformin. Which of the following should the nurse educate the client about?
- A. It can cause weight gain
- B. It should be taken with meals
- C. It is an injectable medication
- D. It can cause hypoglycemia
Correct answer: B
Rationale: The correct answer is B: 'It should be taken with meals.' Metformin should be taken with meals to minimize gastrointestinal side effects and improve absorption. Choice A is incorrect because metformin is actually associated with weight loss or weight neutrality. Choice C is incorrect as metformin is typically taken orally and not via injection. Choice D is also incorrect because metformin is not known to cause hypoglycemia as a primary side effect.
3. A nurse is assessing a 2-hour-old newborn for cold stress. Which of the following findings should the nurse expect?
- A. Respiratory rate of 60/min
- B. Jitteriness of the hands
- C. Diaphoresis
- D. Bounding peripheral pulses
Correct answer: B
Rationale: The correct answer is B: Jitteriness of the hands. Jitteriness is a key sign of cold stress in a newborn, indicating the need for immediate warming measures. A respiratory rate of 60/min may not be directly indicative of cold stress. Diaphoresis (excessive sweating) and bounding peripheral pulses are not typical findings associated with cold stress in newborns.
4. A nurse is caring for a client who has mild anxiety. Which of the following findings should the nurse expect?
- A. Feelings of dread
- B. Rapid speech
- C. Purposeless activity
- D. Heightened perceptual field
Correct answer: D
Rationale: In mild anxiety, the client is expected to have a heightened perceptual field. This means that their perception is increased, enhancing their awareness and ability to concentrate. Feelings of dread (Choice A) are more common in moderate to severe anxiety. Rapid speech (Choice B) and purposeless activity (Choice C) are more indicative of moderate to severe anxiety where the individual may exhibit signs of agitation and restlessness.
5. When planning to discharge a client receiving home oxygen therapy, which of the following instructions should the nurse include in the discharge teaching?
- A. Ensure that electrical cords are not frayed
- B. Keep oxygen tanks in a horizontal position
- C. Store extra oxygen tanks in a closed closet
- D. Apply petroleum-based gel to the inside of the nostrils
Correct answer: A
Rationale: The correct answer is to ensure that electrical cords are not frayed. Frayed electrical cords pose a fire hazard when oxygen is in use. Keeping oxygen tanks in a horizontal position (Choice B) is important to prevent leaks but is not the priority compared to fire safety. Storing extra oxygen tanks in a closed closet (Choice C) is also important but not as immediate as preventing fire hazards. Applying petroleum-based gel to the inside of the nostrils (Choice D) is unrelated to oxygen therapy safety and is not recommended.
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