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 caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement?
- A. Place several pillows behind the client’s head
- B. Place the client in a Sims' position
- C. Keep the client’s neck in a midline position
- D. Maintain flexion of the client’s hips at a 90° angle
Correct answer: C
Rationale: Keeping the client’s neck in a midline position is essential when caring for a client with increased intracranial pressure (ICP) as it helps promote optimal blood flow and reduces the risk of further increasing ICP. Placing pillows behind the client’s head (Choice A) may not be recommended as it could potentially increase ICP. Putting the client in a Sims' position (Choice B) and maintaining hip flexion at a 90° angle (Choice D) are not directly related to managing increased ICP and are not the priority interventions in this situation.
3. A nurse is admitted to a psychiatric unit and fails to follow her medication regimen. What does this behavior indicate?
- A. Early cognitive impairment
- B. Lack of motivation
- C. Lack of health literacy
- D. Worsening health state
Correct answer: C
Rationale: The correct answer is C, 'Lack of health literacy.' The nurse's inability to follow the medication regimen suggests she may lack health literacy, meaning she may not fully understand how to manage her own health care. Choice A, 'Early cognitive impairment,' is not supported by the information provided in the question as there is no mention of cognitive decline. Choice B, 'Lack of motivation,' is less likely as the behavior is more indicative of a knowledge deficit rather than a lack of drive. Choice D, 'Worsening health state,' is also less likely as the behavior described does not directly imply a worsening health condition but rather a misunderstanding or lack of knowledge on managing health.
4. When educating a patient on the use of levodopa-carbidopa, which information should the nurse include?
- A. It is a cure for Parkinson's disease
- B. Monitor for dyskinesia
- C. It can be taken at any time
- D. It has no side effects
Correct answer: B
Rationale: The correct answer is B: 'Monitor for dyskinesia.' Levodopa-carbidopa can cause dyskinesia as a side effect, which is characterized by involuntary muscle movements. Patients need to be monitored for this adverse effect and instructed to report it to their healthcare provider. Choices A, C, and D are incorrect because levodopa-carbidopa is not a cure for Parkinson's disease, it should be taken at specific times for optimal effect, and it does have side effects, such as dyskinesia.
5. A healthcare provider is providing education on the use of atorvastatin. Which of the following should be included?
- A. Monitor for liver function
- B. It can cause muscle pain
- C. It is safe to take during pregnancy
- D. Both A and B
Correct answer: D
Rationale: Atorvastatin requires monitoring for liver function due to its potential to cause liver abnormalities. It can also lead to muscle pain or weakness, a condition known as myopathy. Choice C is incorrect as atorvastatin is contraindicated during pregnancy due to potential harm to the fetus, making choices A and B the correct options to include in patient education.
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