ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A client is taking levothyroxine. Which of the following findings should indicate that the medication is effective?
- A. Weight loss
- B. Decreased blood pressure
- C. Absence of seizures
- D. Decreased inflammation
Correct answer: A
Rationale: The correct answer is A: Weight loss. Levothyroxine is used to treat hypothyroidism, which is characterized by symptoms such as weight gain. Therefore, weight loss in a client taking levothyroxine indicates that the medication is effective in managing hypothyroidism. Choices B, C, and D are incorrect because levothyroxine primarily affects thyroid function and metabolism, not blood pressure, seizures, or inflammation.
2. A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this finding?
- A. Papule
- B. Vesicle
- C. Macule
- D. Nodule
Correct answer: C
Rationale: The correct term the nurse should use to document this finding is 'Macule.' A macule is a flat, nonpalpable skin lesion that is smaller than 1 cm in diameter. In this case, the lesion described is less than 0.5 cm, making it appropriate to classify it as a macule. 'Papule' (Choice A) refers to a solid, elevated skin lesion, 'Vesicle' (Choice B) is a small fluid-filled blister, and 'Nodule' (Choice D) is a solid, elevated skin lesion that is larger and deeper than a papule, none of which accurately describe the lesion in question.
3. A client has been prescribed enoxaparin. Which of the following instructions should the nurse provide regarding self-administration?
- A. Pinch the skin and inject at a 45-degree angle
- B. Massage the injection site after administering
- C. Administer at a 90-degree angle
- D. Avoid rotating injection sites
Correct answer: A
Rationale: The correct answer is to pinch the skin and inject at a 45-degree angle when administering enoxaparin. This technique helps ensure proper administration of the medication. Massaging the injection site after administering is unnecessary and could increase the risk of bleeding. Administering at a 90-degree angle is not recommended for enoxaparin injections. Rotating injection sites is important to prevent tissue damage and irritation.
4. A nurse is preparing to administer a dose of iron supplement. Which of the following should the nurse do?
- A. Give it with milk
- B. Administer it on an empty stomach
- C. Check blood pressure
- D. Monitor for allergic reactions
Correct answer: B
Rationale: The correct answer is B: Administer it on an empty stomach. Iron supplements are best absorbed on an empty stomach to enhance their absorption. It is important to avoid giving them with milk or dairy products as these can inhibit iron absorption. Checking blood pressure and monitoring for allergic reactions are not directly related to the administration of iron supplements and are not the primary considerations in this case.
5. A client who is Rh-negative is being taught about Rh (D) immune globulin by a nurse. Which statement by the client indicates an understanding of the teaching?
- A. If my partner is Rh-negative, I will not receive the shot.
- B. I will receive the shot after delivery if my baby is Rh-negative.
- C. I should not receive any immunizations for 3 months after the shot.
- D. This shot may be given after birth to protect future pregnancies.
Correct answer: D
Rationale: Choice D is the correct answer because it reflects an understanding of Rh immune globulin administration. Rh immune globulin is given after delivery to prevent sensitization in future pregnancies, particularly if the baby is Rh-positive. Choice A is incorrect because Rh-negative partners do not affect the need for Rh immune globulin. Choice B is incorrect as Rh immune globulin is given if the baby is Rh-positive, not Rh-negative. Choice C is incorrect; there is no requirement to avoid immunizations after receiving Rh immune globulin.
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