ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A nurse is caring for a client prescribed lisinopril. Which of the following medication interactions should the nurse instruct this client about?
- A. Potassium supplements
- B. Ciprofloxacin
- C. Escitalopram
- D. Magnesium supplements
Correct answer: A
Rationale: The correct answer is A: Potassium supplements. Lisinopril, an ACE inhibitor, can increase potassium levels in the body. Therefore, the nurse should instruct the client to avoid potassium supplements to prevent hyperkalemia, a potentially dangerous condition. Choices B, C, and D are incorrect because they do not have significant interactions with lisinopril that would lead to adverse effects like hyperkalemia.
2. A nurse is caring for a client who is 8 hours postpartum following a vaginal birth. The client reports passing large clots and heavy bleeding. Which of the following actions should the nurse take?
- A. Massage the fundus
- B. Administer methylergonovine
- C. Increase the IV fluid rate
- D. Notify the healthcare provider
Correct answer: A
Rationale: Heavy bleeding and the passage of large clots after childbirth can indicate uterine atony. The nurse should first attempt to massage the fundus to stimulate uterine contractions and control the bleeding. Massaging the fundus helps the uterus to contract and may help prevent further bleeding. Administering methylergonovine (Choice B) is not the initial intervention for uterine atony. Increasing the IV fluid rate (Choice C) may not address the underlying cause of the bleeding. Notifying the healthcare provider (Choice D) can be done after attempting initial interventions like fundal massage.
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 caring for a client who has a new prescription for an antidepressant. The client reports experiencing dry mouth. Which of the following instructions should the nurse give the client?
- A. Decrease fluid intake.
- B. Chew sugarless gum.
- C. Avoid using mouthwash.
- D. Increase intake of dairy products.
Correct answer: B
Rationale: The correct answer is to instruct the client to chew sugarless gum. Chewing sugarless gum can help alleviate dry mouth by stimulating saliva production, which is a common side effect of many antidepressants. Decreasing fluid intake (choice A) is not recommended as it can worsen dry mouth. Avoiding mouthwash (choice C) is not as effective as chewing gum in stimulating saliva. Increasing intake of dairy products (choice D) is not directly related to managing dry mouth caused by antidepressants.
5. A nurse is caring for a client receiving radiation treatments for cancer. The client states he is experiencing dryness, redness, and scaling at the treatment area. Which of the following should the nurse instruct the client to do?
- A. Sit in the sun for 15 minutes per day.
- B. Apply moist heat to the area twice daily.
- C. Liberally apply prescribed lotion to the area.
- D. Wash the affected area daily with antimicrobial soap.
Correct answer: C
Rationale: The nurse should instruct the client to liberally apply prescribed lotion to the treatment area. Prescribed hydrating lotions help soothe and protect irradiated skin, reducing dryness, redness, and scaling. Sitting in the sun can further damage the skin. Applying moist heat may exacerbate the skin condition. Washing the area with antimicrobial soap can be too harsh and further irritate the skin.
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