ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A nurse is caring for a client prescribed metoprolol. Which of the following should the nurse monitor for as an adverse effect of this medication?
- A. Bradycardia
- B. Hypotension
- C. Tachycardia
- D. Hyperglycemia
Correct answer: B
Rationale: The correct answer is B: Hypotension. Metoprolol, a beta-blocker, can lead to a decrease in blood pressure, resulting in hypotension. Monitoring blood pressure regularly is essential to detect and manage this adverse effect. Choices A, C, and D are incorrect because metoprolol typically does not cause bradycardia, tachycardia, or hyperglycemia as its primary adverse effects.
2. A nurse is providing teaching about the Mediterranean diet to a client who has a new diagnosis of hypertension. Which of the following statements by the client indicates a need for further teaching?
- A. I will limit my intake of red meat to twice monthly.
- B. I can have dairy in moderate portions daily.
- C. I can have fish two times a week.
- D. I can drink wine in moderation.
Correct answer: A
Rationale: The correct answer is A. In the Mediterranean diet, red meat should be limited to two times monthly, not weekly. Choice B is correct as dairy in moderate portions daily is suitable for the Mediterranean diet. Choice C is also correct as having fish two times a week aligns with the Mediterranean diet. Choice D is correct as moderate wine consumption is a component of the Mediterranean diet.
3. A healthcare professional is assessing a client for signs of fluid overload. Which of the following findings should the healthcare professional look for?
- A. Weight loss
- B. Decreased blood pressure
- C. Edema
- D. Increased urine output
Correct answer: C
Rationale: Edema is a common sign of fluid overload. When the body retains more fluid than it excretes, it can lead to edema, which is swelling caused by excess fluid trapped in body tissues. Weight gain, not weight loss, is typically associated with fluid overload due to the retained fluids. Decreased blood pressure is more commonly associated with dehydration rather than fluid overload. Increased urine output is a sign of the body trying to eliminate excess fluids, which is contrary to the signs of fluid overload.
4. A nurse is caring for a client who had a stroke and is showing signs of dysphagia. Which of the following findings should the nurse recognize as an indication of this condition?
- A. Abnormal movements of the mouth
- B. Inability to stand without assistance
- C. Paralysis of the right arm
- D. Loss of appetite
Correct answer: A
Rationale: Abnormal movements of the mouth are a common indication of dysphagia, a condition that impairs swallowing function. In clients who have had a stroke, dysphagia can increase the risk of aspiration, leading to serious complications. Inability to stand without assistance (Choice B) is more indicative of motor deficits following a stroke rather than dysphagia. Paralysis of the right arm (Choice C) is a manifestation of hemiplegia, which is common in stroke but not directly related to dysphagia. Loss of appetite (Choice D) may occur in individuals with dysphagia but is not a direct indicator of the condition itself.
5. A nurse is preparing to insert an indwelling urinary catheter into a female client. Which of the following actions should the nurse take?
- A. Inflate the balloon with 10 mL of sterile water prior to insertion
- B. Cleanse the client’s labia and meatus using a front-to-back motion
- C. Ask the client to bear down while inserting the catheter
- D. Inflate the catheter balloon after urine begins to flow
Correct answer: D
Rationale: The correct action for the nurse to take when inserting an indwelling urinary catheter into a female client is to inflate the catheter balloon after urine begins to flow. Inflating the balloon before urine starts flowing can lead to incorrect placement in the urethra, causing trauma. Cleansing the labia and meatus should be done before the insertion, but the crucial step of inflating the balloon should occur after the catheter is correctly placed. Asking the client to bear down is not necessary during catheter insertion.
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