ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is caring for a newborn immediately following birth. What should the nurse do first?
- A. Instill erythromycin ophthalmic ointment
- B. Place identification bracelets on the newborn
- C. Weigh the newborn
- D. Dry the newborn
Correct answer: D
Rationale: Drying the newborn is the first priority to prevent heat loss, which can occur rapidly in newborns due to their large surface area and lack of body fat. This helps maintain the newborn's body temperature and prevent hypothermia. Instilling erythromycin ophthalmic ointment, placing identification bracelets, and weighing the newborn can be important steps but should come after ensuring the newborn is dried to maintain their body temperature.
2. A nurse is teaching a client about nonpharmacological pain management techniques. Which statement about hypnosis is appropriate?
- A. Hypnosis promotes increased control of pain perception during labor
- B. Hypnosis uses therapeutic touch to reduce anxiety
- C. Hypnosis focuses on biofeedback as a relaxation technique
- D. Hypnosis provides instruction to minimize pain
Correct answer: A
Rationale: The correct answer is A: "Hypnosis promotes increased control of pain perception during labor." Hypnosis can be effectively utilized during labor to help individuals enhance their control over how they perceive pain. Choice B is incorrect because hypnosis does not primarily use therapeutic touch to reduce anxiety. Choice C is incorrect as hypnosis is not primarily focused on biofeedback as a relaxation technique. Choice D is incorrect because hypnosis does not provide direct instructions to minimize pain but rather helps individuals gain control over their pain perception.
3. A nurse is teaching a client about the use of atorvastatin. Which of the following should be included?
- A. Monitor for muscle pain
- B. It can cause weight gain
- C. It is safe during pregnancy
- D. It is an anticoagulant
Correct answer: A
Rationale: The correct answer is A: 'Monitor for muscle pain.' Atorvastatin can cause muscle pain and liver function abnormalities, so clients should be monitored for these side effects. Choice B is incorrect because atorvastatin is not known to cause weight gain. Choice C is incorrect as atorvastatin is contraindicated during pregnancy due to potential harm to the fetus. Choice D is incorrect because atorvastatin is a statin medication used to lower cholesterol levels, not an anticoagulant.
4. A nurse is assessing a client who is 12 hours post-surgery. The client has an indwelling urinary catheter, and the nurse notes a urinary output of 15 mL/hr. Which of the following interventions should the nurse implement first?
- A. Irrigate the catheter
- B. Assess the patency of the catheter
- C. Increase the IV fluid rate
- D. Notify the provider
Correct answer: B
Rationale: The nurse should first assess the patency of the catheter to ensure that the low output is not caused by a blockage. It is crucial to rule out any obstructions before considering other interventions. Irrigating the catheter without verifying patency may worsen the situation if there is a blockage. Increasing IV fluid rate may not address the underlying issue if the problem lies with the catheter. Notifying the provider should come after ensuring the catheter's patency.
5. A newborn demonstrates respiratory distress, and routine suctioning with the bulb syringe is unsuccessful. What is the next nursing intervention?
- A. Initiate chest compressions
- B. Administer oxygen
- C. Suction with a mechanical device
- D. Notify the healthcare provider
Correct answer: C
Rationale: When routine suctioning with a bulb syringe is unsuccessful in a newborn demonstrating respiratory distress, the next appropriate nursing intervention is to suction with a mechanical device. This method ensures effective removal of any airway obstruction. Initiating chest compressions (Choice A) is not indicated in this scenario as the primary concern is airway clearance. Administering oxygen (Choice B) may be necessary, but addressing the airway obstruction should take precedence. Notifying the healthcare provider (Choice D) can be considered after attempting mechanical suction if the newborn's condition does not improve.
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