ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment B Quizlet
1. 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.
2. A nurse is teaching a client about the use of sildenafil. Which of the following should be included?
- A. It should not be taken with nitrates
- B. Monitor for headaches
- C. It is a prescription medication
- D. It may have side effects
Correct answer: B
Rationale: The correct answer is to monitor for headaches when taking sildenafil. This medication can cause headaches and other side effects, so it is crucial to inform clients about these potential adverse reactions. Choice A is incorrect because sildenafil should not be taken with nitrates due to the risk of severe hypotension. Choice C is incorrect as sildenafil is a prescription medication, not an over-the-counter one. Choice D is incorrect because sildenafil, like any medication, can have side effects that should be discussed with the client.
3. A nurse is teaching a group of clients about measures to prevent the development of skin cancer. Which of the following client statements indicates a need for further teaching?
- A. I will avoid going outside between 1000 and 1600.
- B. I will wear a wide-brimmed hat when I go outside.
- C. I will make sure to apply sunscreen with SPF 10 when I’m in the sun.
- D. I will reapply my sunscreen every 2 hours.
Correct answer: C
Rationale: The correct answer is C. An SPF of at least 15 is recommended to effectively protect against harmful UV rays. A sunscreen with an SPF of 10 is insufficient and does not provide adequate protection against skin cancer. Choices A, B, and D demonstrate good understanding of sun protection measures, such as avoiding peak sun hours, wearing protective clothing like a wide-brimmed hat, and reapplying sunscreen every 2 hours, which are all effective strategies to prevent skin cancer.
4. A nurse is caring for a client who has DVT. Which of the following instructions should the nurse include in the plan of care?
- A. Limit the client’s fluid intake to 1500 mL per day
- B. Massage the affected extremity to relieve pain
- C. Apply cold packs to the affected extremity
- D. Elevate the client’s affected extremity when in bed
Correct answer: D
Rationale: The correct instruction the nurse should include in the plan of care for a client with DVT is to elevate the affected extremity when in bed. Elevating the affected extremity helps improve venous return, reduces edema, alleviates discomfort, and promotes healing in clients with DVT. Limiting fluid intake can be detrimental as adequate hydration is important for circulation. Massaging the affected extremity can dislodge clots and worsen the condition. Applying cold packs can cause vasoconstriction, which is not recommended for DVT as it can impede blood flow further.
5. A nurse is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the nurse include in the teaching?
- A. Inhale the medication deeply for 3-5 seconds
- B. Exhale forcefully before inhaling
- C. Shake the MDI vigorously before use
- D. Hold the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth
Correct answer: A
Rationale: Corrected Rationale: Inhaling the medication deeply for 3-5 seconds and holding the breath for 10 seconds after inhalation ensures effective medication delivery to the lungs. Choice A is the correct instruction for the use of a metered-dose inhaler (MDI). Choice B, exhaling forcefully before inhaling, is incorrect as it can lead to decreased medication delivery. Choice C, shaking the MDI vigorously before use, is also incorrect as excessive shaking can cause the medication to clump. Choice D, holding the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth, is not recommended as it may lead to improper inhalation technique.
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