ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A client is prescribed furosemide. Which of the following is a potential side effect?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypernatremia
Correct answer: B
Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through urine, causing hypokalemia. Hyperkalemia (choice A) is not a side effect of furosemide. Hyponatremia (choice C) and hypernatremia (choice D) are related to sodium levels rather than potassium, and they are not typically associated with furosemide use.
2. 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.
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 healthcare professional is verifying nasogastric tube placement by the pH of aspirated gastric fluid. Which of the following pH values provides a good indication of correct tube placement?
- A. 2
- B. 5
- C. 7
- D. 9
Correct answer: A
Rationale: The correct answer is A: '2'. Gastric contents with a pH between 0 and 4 provide a good indication of appropriate tube placement. A pH of 2 is within this range, indicating that the tube is correctly placed in the stomach. Choices B, C, and D are incorrect because a pH of 5, 7, or 9 does not fall within the expected acidic pH range of gastric fluid.
5. A nurse is sitting with the partner of a client who recently died. Which action should the nurse take to facilitate mourning?
- A. Offer advice on coping strategies
- B. Encourage the partner to ask for help when needed
- C. Discuss the importance of grieving alone
- D. Suggest the partner avoid talking about the loss
Correct answer: B
Rationale: Encouraging the partner to ask for help when needed is the most appropriate action for the nurse to facilitate mourning. Grieving is a challenging process, and individuals may require support from others to cope effectively. Offering advice on coping strategies, discussing the importance of grieving alone, or suggesting avoiding talking about the loss could hinder the partner's mourning process by isolating them or suppressing their feelings.
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