ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is planning care for a client who has a new diagnosis of deep vein thrombosis (DVT). Which action should the nurse take?
- A. Massage the affected extremity
- B. Elevate the affected leg
- C. Apply cold packs to the affected leg
- D. Keep the leg dependent to increase circulation
Correct answer: B
Rationale: Elevating the leg promotes venous return and reduces swelling, which is crucial for clients with DVT. Massaging the affected extremity can dislodge the clot and worsen the condition. Applying cold packs can cause vasoconstriction, potentially increasing the risk of clot formation. Keeping the leg dependent can impede circulation and increase the risk of clot migration.
2. A healthcare provider is assessing a client who is receiving heparin therapy for deep vein thrombosis (DVT). Which of the following laboratory values should the provider monitor to evaluate the therapeutic effect of the heparin?
- A. Platelet count
- B. Partial thromboplastin time (PTT)
- C. Prothrombin time (PT)
- D. Bleeding time
Correct answer: B
Rationale: The Partial Thromboplastin Time (PTT) is the correct laboratory value to monitor heparin therapy. PTT measures the time it takes for blood to clot and is specifically used to evaluate the effectiveness of anticoagulation therapy such as heparin. Monitoring the PTT helps ensure that the heparin dose is within the therapeutic range. Platelet count, Prothrombin time (PT), and Bleeding time are not specific laboratory values for monitoring the therapeutic effect of heparin therapy. Platelet count is more indicative of platelet function, PT is used to monitor warfarin therapy, and Bleeding time assesses platelet function rather than the effect of heparin therapy.
3. A healthcare provider is providing education to a client about atorvastatin. Which of the following should be included?
- A. Monitor for muscle pain
- B. Avoid sun exposure
- C. Report any gastrointestinal symptoms
- D. Check liver function tests
Correct answer: A
Rationale: Corrected Rationale: Atorvastatin can cause muscle pain and liver function abnormalities. Monitoring for muscle pain is essential as it can be a sign of a serious side effect called rhabdomyolysis. While liver function tests are necessary before starting atorvastatin, checking them continuously may not be required. Avoiding sun exposure and reporting gastrointestinal symptoms are not directly associated with atorvastatin use.
4. In orienting new staff nurses to a pediatric intensive care unit, what is an important consideration in providing information to parents of a critically ill child?
- A. Making sure they receive complete information during each encounter
- B. Assessing parents' preferences regarding the amount of information
- C. Allowing parents to observe key aspects of their child's care
- D. Providing patient education brochures explaining ICU protocols
Correct answer: B
Rationale: Assessing parents' preferences about the amount of information is crucial because it allows for individualized care that respects their needs and emotional capacity during a stressful time. Choice A is not ideal as overwhelming parents with complete information during each encounter may not align with their preferences. Choice C, while valuable, may not always be feasible or appropriate due to privacy concerns or medical procedures. Choice D, providing brochures, may not address the specific needs or preferences of each set of parents, making it less effective than assessing individual preferences.
5. A client expresses anxiety about an upcoming surgery. What should the nurse do?
- A. Reassure the client that everything will be fine
- B. Ask the client to describe feelings
- C. Tell the client to stay positive
- D. Provide information about the surgery
Correct answer: B
Rationale: Asking the client to describe their feelings is the most appropriate action for the nurse to take. This allows the nurse to understand the specific concerns and anxieties the client is experiencing. Choice A may invalidate the client's feelings and not address the root cause of anxiety. Choice C may come across as dismissive and oversimplified. While providing information about the surgery (Choice D) is important, addressing the client's emotional state is the initial priority in this situation.
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