ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A client receiving opiates for pain management was initially sedated but is no longer sedated after three days. What action should the nurse take?
- A. Initiate additional non-pharmacological pain management techniques.
- B. Notify the provider that a dosage adjustment is needed.
- C. No action is needed at this time.
- D. Contact the provider to request an alternate method of pain management.
Correct answer: C
Rationale: The correct answer is C: No action is needed at this time. Sedation from opiates commonly decreases as the body adjusts to the medication. It is a positive sign that the sedation has resolved, indicating the client is tolerating the current dosage well. Initiating additional non-pharmacological pain management techniques (Choice A) is unnecessary since the current pain management regimen is effective. Notifying the provider for a dosage adjustment (Choice B) is premature and not indicated when the sedation has resolved. Contacting the provider to request an alternate method of pain management (Choice D) is excessive and not warranted in this situation where the client is no longer sedated and the current pain management plan is effective.
2. 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.
3. A healthcare professional is preparing to administer a dose of naloxone. Which of the following should the healthcare professional assess?
- A. Heart rate
- B. Respiratory rate
- C. Blood pressure
- D. Temperature
Correct answer: B
Rationale: Correct. Naloxone is used to reverse opioid overdose, which can cause respiratory depression. Assessing the respiratory rate before administering naloxone is crucial to monitor the patient's breathing. Choices A, C, and D are important assessments in general patient care but are not specifically crucial before administering naloxone for opioid overdose.
4. 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.
5. A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?
- A. Uterine fundus is firm and midline
- B. Client's perineal pad is saturated in 15 minutes
- C. Client reports breast tenderness when breastfeeding
- D. Client's temperature is 100.4°F
Correct answer: B
Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences. A firm and midline uterine fundus indicates proper involution, breast tenderness during breastfeeding is common due to engorgement, and a temperature of 100.4°F is considered within the normal range for the postpartum period.
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