ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is monitoring a client during an IV urography procedure. Which of the following client reports is the priority finding?
- A. Feeling flushed and warm
- B. Abdominal fullness
- C. Swollen lips
- D. Metallic taste in the mouth
Correct answer: C
Rationale: Swollen lips indicate a potential allergic reaction or anaphylaxis to the contrast dye used during the procedure, which requires immediate medical intervention. Abdominal fullness and metallic taste are common side effects of IV urography and can be managed without urgent intervention. Feeling flushed and warm may also be a common reaction during the procedure and does not indicate a life-threatening situation like an allergic reaction.
2. A nurse is preparing to administer a client's first dose of a new antibiotic. Which of the following is the priority nursing action?
- A. Assess the client's allergies.
- B. Monitor the client's vital signs.
- C. Inform the client of potential side effects.
- D. Obtain the client's informed consent.
Correct answer: A
Rationale: Assessing allergies before administering a new medication is crucial as it helps prevent potentially life-threatening allergic reactions like anaphylaxis. While monitoring vital signs and informing the client of side effects are important nursing actions, assessing allergies takes precedence to ensure the client's safety. Informed consent is necessary for the treatment process, but assessing allergies is the priority before administering any new medication.
3. A client newly diagnosed with osteoporosis is being taught by a nurse about preventing complications. Which food should the nurse recommend?
- A. Fried chicken
- B. Whole milk
- C. Oatmeal
- D. Bacon
Correct answer: C
Rationale: Oatmeal is an excellent recommendation for clients with osteoporosis due to its richness in fiber and nutrients, making it a heart-healthy and bone-friendly choice. Fried chicken (Choice A) is high in unhealthy fats and lacks the nutrients needed for bone health. Whole milk (Choice B) contains calcium but can be high in saturated fats, which may not be the best choice for individuals with osteoporosis. Bacon (Choice D) is high in saturated fats and sodium, which can have negative effects on bone health and overall well-being.
4. A nurse is providing discharge teaching for a client who has COPD about nutrition. Which of the following instructions should the nurse include?
- A. Eat three large meals daily
- B. Consume high-calorie, high-protein foods
- C. Limit caffeinated drinks to two per day
- D. Drink fluids between meals
Correct answer: B
Rationale: The correct answer is B: 'Consume high-calorie, high-protein foods.' Clients with COPD often have increased energy needs due to the work of breathing. Consuming high-calorie, high-protein foods can help provide the necessary energy and prevent weight loss. Choice A is incorrect because eating three large meals daily may lead to increased shortness of breath due to a full stomach. Choice C is incorrect because limiting caffeinated drinks is important, but the recommendation should focus on reducing intake, not specifying a number. Choice D is incorrect because drinking fluids during mealtime can lead to early satiety, making it difficult for the client to consume enough calories.
5. A client diagnosed with pneumonia is receiving oxygen therapy at 4 L/min via nasal cannula. Which of the following interventions is most important?
- A. Encourage fluid intake.
- B. Monitor oxygen saturation levels.
- C. Change the oxygen tubing daily.
- D. Assist with frequent position changes.
Correct answer: B
Rationale: Monitoring oxygen saturation levels is the most important intervention in this scenario. It ensures that the client is receiving adequate oxygenation, which is crucial for a client with pneumonia. By monitoring saturation levels, the nurse can promptly identify any oxygenation issues and adjust the oxygen delivery if necessary. Encouraging fluid intake, changing oxygen tubing daily, and assisting with frequent position changes are also important aspects of care for a client with pneumonia, but they are not as critical as monitoring oxygen saturation levels in ensuring immediate respiratory support.
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