ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?
- A. Position the client with the affected extremity lower than the heart
- B. Administer acetaminophen for pain
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct answer: D
Rationale: Withholding heparin IV infusion is the priority if there is a risk of complications such as bleeding, which must be evaluated before continuing treatment.
2. A charge nurse is preparing an educational session about addictive disorders for nursing staff. Which of the following should the nurse include as an etiological factor of addictive disorder?
- A. Low self-esteem
- B. Family history of addiction
- C. Personality disorders
- D. All of the above
Correct answer: D
Rationale: The correct answer is D: All of the above. Addiction is influenced by various factors, including low self-esteem, family history of addiction, and specific personality traits. Low self-esteem can lead individuals to seek solace in substances, a family history of addiction can increase the likelihood of developing addictive behaviors due to genetic and environmental factors, and certain personality disorders may contribute to addictive tendencies. Therefore, all the factors listed in choices A, B, and C can play a role in the development of addictive disorders. Choices A, B, and C are incorrect because addictive disorders are multifactorial, and it is essential to consider a combination of influences rather than isolating a single factor.
3. 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.
4. A nurse is caring for a client newly prescribed doxazosin mesylate. Which of the following instructions should the nurse include in client education regarding taking the first dose of this medication?
- A. Change positions slowly and lie down if dizziness occurs
- B. There is no need to avoid normal activities
- C. Avoid dairy products while taking this medication
- D. Do not eat green leafy vegetables
Correct answer: A
Rationale: The correct answer is A. Doxazosin can cause first-dose orthostatic hypotension, which may lead to dizziness or fainting when the client stands up too quickly. The nurse should advise the client to change positions slowly and lie down if dizziness occurs to prevent falls and other injuries. Choice B is incorrect because while the client can continue normal activities, caution should be taken with position changes. Choice C is incorrect as doxazosin does not interact with dairy products. Choice D is incorrect as there is no need to avoid green leafy vegetables specifically while taking doxazosin.
5. A nurse is discussing immunity with a client who has received an immunization. The nurse should identify that an immunization functions as part of which of the following types of immunity?
- A. Innate immunity
- B. Passive immunity
- C. Acquired immunity
- D. Natural immunity
Correct answer: C
Rationale: Immunizations provide acquired immunity. They work by introducing antigens into the body, which triggers the immune system to produce antibodies specific to that antigen. Choice A, 'Innate immunity,' refers to the natural defense mechanisms an organism is born with and does not involve immunizations. Choice B, 'Passive immunity,' is the transfer of pre-formed antibodies and does not involve immunizations. Choice D, 'Natural immunity,' is a general term that encompasses all immunity that is not acquired through deliberate immunization or passive transfer of antibodies.
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