ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is caring for a client in the second trimester of pregnancy and asks how to treat constipation. Which of the following statements by the nurse is appropriate?
- A. Decrease intake of vitamins and supplements to every other day
- B. Eat 15 g of fiber per day
- C. Consume 48 ounces of water each day
- D. Drink hot water with lemon juice each morning
Correct answer: D
Rationale: The correct answer is D. Drinking hot water with lemon juice in the morning is a natural and safe way to stimulate bowel movements and relieve constipation during pregnancy. Option A is incorrect as vitamins and supplements should not be decreased without consulting a healthcare provider, especially during pregnancy. Option B is inadequate as the recommended daily fiber intake during pregnancy is higher than 15g. Option C, while important for overall health, does not directly address constipation relief in pregnancy.
2. A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?
- A. Proceed with the dressing change
- B. Restart the procedure if the sterile solution splashes onto the sterile field
- C. Continue without concern for minor splashes
- D. Delegate the task to another nurse
Correct answer: B
Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.
3. A client who is Rh-negative is being taught about Rh (D) immune globulin by a nurse. Which statement by the client indicates an understanding of the teaching?
- A. If my partner is Rh-negative, I will not receive the shot.
- B. I will receive the shot after delivery if my baby is Rh-negative.
- C. I should not receive any immunizations for 3 months after the shot.
- D. This shot may be given after birth to protect future pregnancies.
Correct answer: D
Rationale: Choice D is the correct answer because it reflects an understanding of Rh immune globulin administration. Rh immune globulin is given after delivery to prevent sensitization in future pregnancies, particularly if the baby is Rh-positive. Choice A is incorrect because Rh-negative partners do not affect the need for Rh immune globulin. Choice B is incorrect as Rh immune globulin is given if the baby is Rh-positive, not Rh-negative. Choice C is incorrect; there is no requirement to avoid immunizations after receiving Rh immune globulin.
4. A nurse is providing discharge teaching to a client with a new prescription for furosemide. Which client statement indicates a need for further teaching?
- A. I will take my morning pills with food or milk.
- B. I will weigh myself every day.
- C. I will notify the nurse if I have muscle cramps.
- D. I will limit my intake of fish.
Correct answer: D
Rationale: The correct answer is D. Furosemide is a diuretic that does not require a reduction in fish consumption. Therefore, the statement 'I will limit my intake of fish' indicates a misunderstanding of dietary considerations. Choices A, B, and C are all appropriate actions related to furosemide therapy. Taking pills with food or milk can help reduce stomach upset, daily weight monitoring is crucial due to the diuretic effect of furosemide, and notifying the nurse about muscle cramps is important as it can be a sign of electrolyte imbalance, a potential side effect of furosemide.
5. A community health nurse is reviewing primary prevention for West Nile virus with a group of patients in a rural health clinic. What instructions should the nurse include?
- A. Eliminate areas of standing water.
- B. Wear a mask when outdoors.
- C. Ensure food is cooked thoroughly.
- D. Avoid contact with sick individuals.
Correct answer: A
Rationale: The correct answer is A: 'Eliminate areas of standing water.' Standing water provides breeding grounds for mosquitoes, which spread West Nile virus. By eliminating standing water, individuals can reduce the risk of mosquito breeding and the transmission of the virus. Choices B, C, and D are incorrect. Wearing a mask when outdoors, ensuring food is cooked thoroughly, and avoiding contact with sick individuals are not directly related to primary prevention strategies for West Nile virus.
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