ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is caring for a client with deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
- A. Position the client with the affected leg below the heart
- B. Massage the affected extremity every 4 hours
- C. Apply cold compresses to the affected extremity
- D. Elevate the affected leg while in bed
Correct answer: D
Rationale: The correct answer is to elevate the affected leg while in bed. Elevating the leg helps reduce swelling and promotes venous return, aiding in the management of DVT. Positioning the affected leg below the heart can worsen the condition by increasing the risk of clot dislodgment. Massaging the affected extremity can also dislodge the clot and should be avoided. Cold compresses are not recommended as they can cause vasoconstriction, potentially worsening the condition.
2. A healthcare professional is preparing to administer a dose of potassium chloride. Which of the following should the professional do?
- A. Administer it as a bolus
- B. Dilute the medication
- C. Give it rapidly
- D. Monitor respiratory rate
Correct answer: B
Rationale: Correct Answer: Dilute the medication. Potassium chloride should always be diluted before administration to avoid irritation and complications. Choice A is incorrect because administering it as a bolus can lead to adverse effects. Choice C is incorrect as giving it rapidly can be dangerous. Choice D is incorrect as monitoring the respiratory rate is not directly related to administering potassium chloride.
3. A nurse is planning to administer several medications to a client through an NG tube. Which actions should the nurse take?
- A. Dissolve crushed tablet medications in tap water
- B. Use 30-40 mL of sterile water for each medication
- C. Dissolve crushed tablet medications in sterile water
- D. Administer medications without dissolving
Correct answer: C
Rationale: The correct action for the nurse to take when administering medications through an NG tube is to dissolve crushed tablet medications in 15-30 mL of sterile water. This ensures proper delivery through the NG tube and reduces the risk of clogging. Choice A is incorrect because tap water may contain impurities that can cause complications. Choice B suggests using a higher volume of sterile water than necessary, which may lead to dilution of the medications. Choice D is incorrect as medications should be dissolved to prevent blockages in the NG tube.
4. A nurse in the emergency department is prioritizing care for four clients. Which of the following clients should the nurse see first?
- A. A 6-year-old with a dislocated shoulder
- B. A 26-year-old with sickle cell disease and severe joint pain
- C. A 76-year-old with confusion, fever, and foul-smelling urine
- D. A 50-year-old with slurred speech, disorientation, and headache
Correct answer: D
Rationale: The client with slurred speech, disorientation, and a headache may be experiencing a stroke, a life-threatening condition that requires immediate attention. Identifying and managing a stroke promptly can reduce the risk of long-term disability or complications. The other options, although important, do not present immediate life-threatening conditions that require urgent intervention. A dislocated shoulder, severe joint pain in sickle cell disease, confusion with fever and foul-smelling urine, while concerning, can be addressed after attending to the client with potential stroke symptoms.
5. A healthcare provider is caring for a client receiving total parenteral nutrition (TPN). Which of the following should the healthcare provider monitor?
- A. Serum glucose levels
- B. Serum potassium levels
- C. Blood pressure
- D. Both A and B
Correct answer: D
Rationale: When caring for a client receiving total parenteral nutrition (TPN), monitoring serum glucose levels is essential due to the impact TPN can have on glucose metabolism. Additionally, electrolytes like potassium should be monitored as they can be affected by TPN administration. Blood pressure monitoring is not directly related to TPN administration, making choices A and B the correct options to monitor in this scenario.
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