ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A client with chronic renal failure needs dietary instructions. Which of the following should the nurse provide?
- A. Increase calcium intake
- B. Provide a diet high in potassium
- C. Restrict protein intake
- D. Increase fluid intake
Correct answer: C
Rationale: The correct answer is to instruct the client to restrict protein intake. In chronic renal failure, the kidneys are unable to effectively filter waste products, so limiting protein helps reduce the buildup of waste in the body. Increasing calcium intake (Choice A) is not typically necessary unless there is a specific deficiency. Providing a diet high in potassium (Choice B) is contraindicated as potassium levels need to be monitored and controlled in renal failure. Increasing fluid intake (Choice D) may be necessary depending on the individual's condition, but restricting protein intake is a more critical dietary instruction for clients with chronic renal failure.
2. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which is a contraindication for this vaccine?
- A. Recent blood transfusion
- B. Allergy to penicillin
- C. Minor acute illness
- D. Low-grade fever
Correct answer: A
Rationale: The correct answer is A: Recent blood transfusion. A recent blood transfusion can interfere with the effectiveness of the MMR vaccine, making it a contraindication. Choice B, allergy to penicillin, is not a contraindication for the MMR vaccine. Choice C, minor acute illness, is not a contraindication unless the child has a moderate to severe illness. Choice D, low-grade fever, is not a contraindication as long as the child does not have a moderate to severe febrile illness.
3. Which of the following would increase a client's risk of ovarian cancer?
- A. History of fibroids
- B. Early menopause
- C. Endometriosis
- D. Polycystic ovary syndrome
Correct answer: C
Rationale: The correct answer is C, Endometriosis. Endometriosis is associated with an increased risk of developing ovarian cancer due to chronic inflammation and hormonal imbalances. The exact cause is not fully understood, but women with endometriosis should be monitored closely. Choices A, B, and D are incorrect as they are not directly linked to an increased risk of ovarian cancer. Fibroids, early menopause, and polycystic ovary syndrome do not have a known direct correlation with ovarian cancer risk.
4. A nurse is teaching about measures to promote sleep for a client with insomnia. What statement indicates understanding?
- A. I should reduce my fluid intake to 2 hours before bedtime
- B. I will watch TV in bed before sleeping
- C. I can take long naps during the day
- D. I should exercise right before going to bed
Correct answer: A
Rationale: The correct answer is A. Reducing fluid intake to 2-4 hours before sleeping helps prevent interruptions during the night, promoting better sleep. Watching TV in bed before sleeping (choice B) can actually hinder sleep due to the stimulation from screens. Taking long naps during the day (choice C) can disrupt the natural sleep-wake cycle. Exercising right before going to bed (choice D) can increase alertness and make it harder to fall asleep.
5. A client who is 38 weeks pregnant with herpes simplex virus is admitted to labor and delivery. What question should the nurse ask?
- A. Do you have any active lesions?
- B. Have your membranes ruptured?
- C. How far apart are your contractions?
- D. Are you positive for beta strep?
Correct answer: A
Rationale: The correct question the nurse should ask the client who is 38 weeks pregnant with herpes simplex virus is 'Do you have any active lesions?' This is crucial because active herpes lesions may necessitate a cesarean delivery to prevent neonatal infection. Choice B, 'Have your membranes ruptured?' is related to assessing for the rupture of membranes, not specific to the client's herpes infection. Choice C, 'How far apart are your contractions?' is related to monitoring labor progress. Choice D, 'Are you positive for beta strep?' is related to group B streptococcus screening, which is important but not the priority in this scenario.
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