ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A nurse is caring for a client with a new prescription for furosemide. Which of the following should the nurse monitor?
- A. Serum potassium levels
- B. Liver function
- C. Blood glucose levels
- D. Calcium levels
Correct answer: A
Rationale: Corrected Rationale: When a client is prescribed furosemide, the nurse should monitor serum potassium levels. Furosemide is a loop diuretic that can lead to potassium loss, potentially causing hypokalemia. Monitoring serum potassium levels is crucial to prevent complications such as cardiac dysrhythmias. Choices B, C, and D are incorrect because furosemide primarily affects potassium excretion rather than liver function, blood glucose levels, or calcium levels.
2. A client with hypertension is being taught about dietary modifications by a nurse. Which of the following food choices should the nurse recommend?
- A. Canned tomato soup
- B. Baked chicken breast
- C. Processed cheese
- D. Pickled vegetables
Correct answer: B
Rationale: The correct answer is Baked chicken breast. It is low in sodium and a healthy option for clients with hypertension. Canned tomato soup and processed cheese are typically high in sodium, which is not recommended for individuals with hypertension. Pickled vegetables are also high in sodium and should be avoided in a hypertension-friendly diet.
3. A nurse enters a patient's room and finds the client pulseless. The living will requests no resuscitation be performed, but the provider has not written the prescription. What action should the nurse take?
- A. Notify the family.
- B. Begin CPR.
- C. Await further instructions from the provider.
- D. Document the event.
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to begin CPR. Even though the living will requests no resuscitation, without a written do-not-resuscitate (DNR) order from the provider, the nurse is ethically and legally bound to initiate CPR to provide life-saving measures until further confirmation is obtained. Notifying the family (Choice A) may cause a delay in providing immediate care. Waiting for further instructions (Choice C) can be time-consuming and compromise patient outcomes. Documenting the event (Choice D) is important but should follow after initiating CPR to ensure patient safety and adherence to protocols.
4. A nurse is caring for a client who has dehydration. The client has a peripheral IV and has a prescription for an infusion of 0.9% sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr. Which of the following actions should the nurse take first?
- A. Teach the client to report findings of IV extravasation
- B. Evaluate the patency of the IV
- C. Consult with the pharmacist about the prescription
- D. Verify the prescription with the provider
Correct answer: D
Rationale: The priority action is to verify the prescription with the provider. Verifying the prescription ensures patient safety by preventing fluid volume overload and dysrhythmias, which can result from infusing potassium too rapidly. Teaching the client about IV extravasation, evaluating IV patency, and consulting with the pharmacist are important but should come after verifying the prescription to ensure the ordered treatment is appropriate and safe for the client's condition.
5. A nurse working in a mobile health clinic is assessing a migrant farm worker. What finding should the nurse identify as a priority?
- A. Report of fatigue and fever
- B. Report of muscle twitching and skin rash
- C. Report of blurred vision
- D. Report of nasal congestion
Correct answer: B
Rationale: Muscle twitching and a skin rash may indicate exposure to pesticides, which requires immediate intervention due to potential toxicity. Fatigue and fever (Choice A) are non-specific symptoms that may indicate various conditions but do not directly indicate pesticide exposure. Blurred vision (Choice C) and nasal congestion (Choice D) are also non-specific symptoms and are less likely to be related to pesticide exposure compared to muscle twitching and a skin rash.
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