ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is caring for a client with a new prescription for enoxaparin to prevent DVT. Which of the following is an appropriate action by the nurse?
- A. Expel any air bubbles from the prefilled syringe
- B. Inject the medication in the lateral abdominal wall
- C. Massage the injection site to evenly distribute the medication
- D. Administer NSAIDs for injection site discomfort
Correct answer: B
Rationale: The correct answer is to inject enoxaparin in the lateral abdominal wall. This site is typically recommended for subcutaneous injections of this medication. Expelling air bubbles from prefilled syringes is not necessary and may result in medication loss. Massaging the injection site is contraindicated as it can cause bruising or hematoma formation. Administering NSAIDs for injection site discomfort is unnecessary and not a standard practice.
2. A client is admitted for observation and has full range of motion. Which is the best manner to encourage the client to void?
- A. Urinal
- B. Bedpan
- C. Bedside Commode
- D. Client Bathroom
Correct answer: D
Rationale: The correct answer is D: Client Bathroom. Encouraging the client to use the bathroom is the best way to promote independence and privacy, maintaining normal function. In this case, since the client has full range of motion, using the client bathroom would be the most appropriate choice. Options A, B, and C (Urinal, Bedpan, Bedside Commode) are not the best choices as they may restrict the client's independence and privacy, which can impact their psychological well-being and normal voiding function.
3. A nurse is reviewing the guidelines for reporting nationally notifiable infectious diseases. What disease should the nurse report to the CDC?
- A. Measles
- B. Hepatitis A
- C. Lyme disease
- D. Zika
Correct answer: C
Rationale: The correct answer is Lyme disease. Lyme disease must be reported to the CDC as it is a nationally notifiable infectious disease. It is spread by ticks and can lead to significant health issues if not monitored. Measles, Hepatitis A, and Zika are also important infectious diseases, but in this case, Lyme disease is the appropriate choice based on the information provided.
4. A nurse is preparing to administer a dose of digoxin. Which of the following should the nurse do first?
- A. Assess blood pressure
- B. Check heart rate
- C. Monitor potassium levels
- D. Review the medication order
Correct answer: B
Rationale: The correct answer is to check the heart rate first before administering digoxin. Digoxin is a medication that directly affects the heart, so it is crucial to ensure that the heart rate is within the appropriate range before giving the dose. If the heart rate is below 60 bpm, administering digoxin could lead to toxicity. Assessing blood pressure (Choice A) is important but not the first priority when preparing to administer digoxin. Monitoring potassium levels (Choice C) is also crucial for patients on digoxin, but it is not the initial step. Reviewing the medication order (Choice D) is necessary but can be done after checking the heart rate.
5. A client is being educated by a nurse on nutritional intake. Which of the following should the nurse include in the teaching?
- A. Carbohydrates should be at least 45% of your caloric intake
- B. Protein should be at least 55% of your caloric intake
- C. Carbohydrates should be at least 30% of your caloric intake
- D. Protein should be at least 60% of your caloric intake
Correct answer: A
Rationale: Carbohydrates should make up 45-65% of daily caloric intake as they are the body’s main source of energy. This aligns with general dietary recommendations. Choice B is incorrect as protein should typically make up about 10-35% of daily caloric intake, not 55%. Choice C is also incorrect, as carbohydrates should ideally be between 45-65%, not 30%. Choice D is incorrect because protein should generally account for around 10-35% of total caloric intake, not 60%.
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