ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is caring for a client recovering from bowel surgery who has a nasogastric (NG) tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?
- A. Drainage fluid is greenish-yellow
- B. Aspirate pH of 3
- C. Abdominal rigidity
- D. Air bubbles noted in the NG tube
Correct answer: C
Rationale: Abdominal rigidity can indicate a serious complication, such as a blockage or infection, requiring immediate intervention to determine if the NG tube is functioning properly. Choices A, B, and D are not indicative of a malfunctioning NG tube. Greenish-yellow drainage fluid may be normal, an aspirate pH of 3 is within the expected range for gastric contents, and air bubbles in the NG tube are not abnormal as long as they are moving.
2. A healthcare professional is preparing to administer a dose of potassium chloride. Which of the following actions should the healthcare professional take?
- A. Administer rapidly
- B. Dilute the medication before administration
- C. Give it as a bolus
- D. Administer it intramuscularly
Correct answer: B
Rationale: The correct action when administering potassium chloride is to dilute the medication before administration. Potassium chloride is a highly concentrated solution that can cause irritation and potential complications if not properly diluted. Administering it rapidly (choice A) can lead to adverse effects. Giving it as a bolus (choice C) or administering it intramuscularly (choice D) are inappropriate routes for potassium chloride administration and can result in harm to the patient.
3. A nurse is preparing to teach a client with chronic renal failure. Which dietary instruction is most appropriate?
- A. Increase calcium intake
- B. Increase potassium intake
- C. Increase protein intake
- D. Restrict protein intake
Correct answer: D
Rationale: The correct answer is to restrict protein intake for a client with chronic renal failure. In renal failure, the kidneys are unable to effectively filter waste products. Excessive protein intake can lead to the accumulation of waste products, increasing the workload on the kidneys. Therefore, restricting protein intake is essential to prevent further kidney damage. Choices A, B, and C are incorrect. Increasing calcium intake is not specifically indicated for chronic renal failure. Increasing potassium intake can be dangerous in renal failure as impaired kidneys may not be able to excrete excess potassium. Increasing protein intake is contraindicated in chronic renal failure as it can worsen kidney function and increase the accumulation of waste products.
4. A healthcare provider is providing education on the use of atorvastatin. Which of the following should be included?
- A. Monitor for liver function
- B. It can cause muscle pain
- C. It is safe to take during pregnancy
- D. Both A and B
Correct answer: D
Rationale: Atorvastatin requires monitoring for liver function due to its potential to cause liver abnormalities. It can also lead to muscle pain or weakness, a condition known as myopathy. Choice C is incorrect as atorvastatin is contraindicated during pregnancy due to potential harm to the fetus, making choices A and B the correct options to include in patient education.
5. A nurse is teaching a client who has hypertension about dietary modifications to help control blood pressure. Which of the following food choices should the nurse recommend as the best choice for the client to include in their diet?
- A. 1 packet of reconstituted dry onion soup
- B. 3 oz of lean cured ham
- C. 3 oz of chicken breast
- D. 1/2 cup of canned baked beans
Correct answer: C
Rationale: A low sodium diet is recommended for a client who has hypertension. Therefore, the nurse should recommend 3 oz of chicken breast as the best choice for the client's diet because it contains 30 – 90 mg of sodium. Choice A, 1 packet of reconstituted dry onion soup, and Choice B, 3 oz of lean cured ham, are high in sodium content, which is not suitable for a client with hypertension. Choice D, 1/2 cup of canned baked beans, is also high in sodium, making it a less suitable choice compared to 3 oz of chicken breast.
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