ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is caring for a toddler with respiratory syncytial virus (RSV). Which action should the nurse take?
- A. Use a designated stethoscope for the toddler
- B. Wear an N95 respirator mask when caring for the toddler
- C. Place the toddler in a negative pressure room
- D. Remove the disposable gown before leaving the toddler's room
Correct answer: A
Rationale: Using a designated stethoscope for the toddler is crucial to reduce the risk of spreading RSV to other patients. Choice B is incorrect because N95 respirator masks are not specifically indicated for RSV. Choice C is unnecessary as RSV does not require isolation in a negative pressure room. Choice D is incorrect because the gown should be removed after leaving the room to prevent transmission of pathogens to other areas.
2. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?
- A. Fever
- B. Rash
- C. Fatigue
- D. Increased appetite
Correct answer: B
Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.
3. A client has been prescribed phenytoin. Which of the following should the nurse monitor to prevent toxicity?
- A. Blood pressure
- B. Complete blood count
- C. Serum phenytoin levels
- D. Liver function tests
Correct answer: C
Rationale: Corrected Rationale: Serum phenytoin levels should be regularly monitored to prevent toxicity because the therapeutic range is narrow. Monitoring blood pressure (choice A), complete blood count (choice B), and liver function tests (choice D) are not directly related to preventing phenytoin toxicity.
4. A healthcare provider is reviewing a prescription for doxazosin with a client. Which instruction should the healthcare provider provide?
- A. Decrease caloric intake to reduce weight gain
- B. Increase dietary fiber to prevent constipation
- C. Rise slowly when sitting up
- D. Take this medication each morning
Correct answer: C
Rationale: The correct instruction for a client prescribed with doxazosin is to rise slowly when sitting up. Doxazosin can cause orthostatic hypotension, leading to dizziness upon sudden position changes. Instructing the client to rise slowly helps prevent this side effect. Choices A, B, and D are incorrect because they are not directly related to the potential side effects or administration of doxazosin.
5. A nurse is planning care for a client who has a latex allergy and is scheduled for surgery. Which of the following actions should the nurse take?
- A. Apply tape to the client’s skin before surgery.
- B. Ensure the surgical suite is well-ventilated.
- C. Wrap monitoring cords with stockinette.
- D. Schedule the surgery at the end of the day.
Correct answer: C
Rationale: The correct action the nurse should take is to wrap monitoring cords with stockinette. This measure ensures that the latex in the cords does not come into contact with the client’s skin, reducing the risk of an allergic reaction. Applying tape to the client’s skin before surgery (Choice A) may expose the client to latex if the tape contains latex. Ensuring the surgical suite is well-ventilated (Choice B) is important for overall safety but does not specifically address the client's latex allergy. Scheduling the surgery at the end of the day (Choice D) is not directly related to preventing latex exposure and allergic reactions.
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