ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse is caring for a client who is at 14 weeks of gestation and has hyperemesis gravidarum. Which of the following medications should the nurse plan to administer?
- A. Digoxin
- B. Calcium gluconate
- C. Vitamin B6
- D. Propranolol
Correct answer: C
Rationale: The correct answer is C: Vitamin B6 (pyridoxine). Vitamin B6 is often used to treat nausea and vomiting in pregnancy, including hyperemesis gravidarum. It is considered safe for use in pregnant clients. Digoxin (Choice A) is a medication used for heart conditions, not for hyperemesis gravidarum. Calcium gluconate (Choice B) is used to treat calcium deficiencies, not nausea and vomiting in pregnancy. Propranolol (Choice D) is a beta-blocker used for conditions like hypertension and anxiety, not for hyperemesis gravidarum.
2. A nurse is caring for a client prescribed sildenafil for erectile dysfunction. Which of the following should the nurse monitor?
- A. Blood pressure
- B. Heart rate
- C. Temperature
- D. Respiratory rate
Correct answer: A
Rationale: The correct answer is A: Blood pressure. Sildenafil, a medication for erectile dysfunction, can cause changes in blood pressure. The nurse should monitor for hypotension as a potential side effect. Monitoring heart rate (choice B) is not a priority when administering sildenafil unless there are pre-existing heart conditions. Temperature (choice C) and respiratory rate (choice D) are typically not directly affected by sildenafil administration, making them less relevant for monitoring in this case.
3. A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?
- A. A client who is able to bear full weight on both lower extremities.
- B. A client who has bilateral leg braces due to paralysis of the lower extremities.
- C. A client who has a right femur fracture with no weight bearing on the affected leg.
- D. A client who has bilateral knee replacements with partial weight bearing on both legs.
Correct answer: C
Rationale: The correct answer is C because a three-point gait is used when the client can bear full weight on one foot and uses crutches and the uninvolved leg to ambulate. Choices A, B, and D are incorrect because they do not meet the criteria for using a three-point gait. Choice A states that the client can bear full weight on both lower extremities, which does not require a three-point gait. Choice B mentions bilateral leg braces due to paralysis, which would not involve using a three-point gait. Choice D describes a client with bilateral knee replacements with partial weight bearing, which also does not align with the use of a three-point gait.
4. When teaching a client about the correct use of a cane, what should the nurse include?
- A. Ensure the cane has a rubber cap
- B. Hold the cane on the stronger side
- C. Flex the elbow slightly when using the cane
- D. Use a quad cane for increased support
Correct answer: B
Rationale: When using a cane, it should be held on the stronger side to provide optimal support and stability. This positioning allows the cane to bear weight effectively and helps in improving balance. Option A about ensuring the cane has a rubber cap is important for preventing slipping but is not directly related to the correct use of the cane. Option C, flexing the elbow slightly, is a general guideline and may vary depending on the individual's height and the type of cane being used. Option D suggesting the use of a quad cane for increased support is not necessary if a standard cane is sufficient for the client's needs.
5. A nurse is caring for a client with Alzheimer's disease. Which action should the nurse include in the care plan to support the client’s cognitive function?
- A. Place a daily calendar in the kitchen
- B. Replace buttoned clothing with zippered items
- C. Replace carpet with hardwood floors
- D. Create variation in the daily routine
Correct answer: A
Rationale: Placing a daily calendar in the kitchen is beneficial for clients with Alzheimer's disease as it helps in orienting them to time and enhances cognitive function. This visual aid can assist in keeping track of days and activities. Choice B, replacing buttoned clothing with zippered items, is more related to promoting independence in dressing rather than directly supporting cognitive function. Choice C, replacing carpet with hardwood floors, focuses on safety and mobility rather than cognitive function. Choice D, creating variation in the daily routine, may be helpful for engagement and stimulation but does not directly address cognitive function as effectively as using a daily calendar.
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