ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A client wearing an arm cast reports numb fingers. Which of the following actions should the nurse take first?
- A. Place the arm in a dependent position
- B. Administer pain medication
- C. Check the client's circulation
- D. Apply a warm compress to the fingers
Correct answer: C
Rationale: The correct answer is to check the client's circulation. Numbness in the fingers may indicate compromised circulation or nerve damage. By assessing the circulation first, the nurse can ensure that the cast is not too tight, which could be cutting off blood flow. Option A is incorrect because placing the arm in a dependent position may worsen circulation issues. Option B is incorrect as administering pain medication does not address the underlying cause of numbness. Option D is incorrect as applying a warm compress could mask circulation issues and is not the priority in this situation.
2. A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?
- A. A client who is able to bear full weight on both lower extremities.
- B. A client who has bilateral leg braces due to paralysis of the lower extremities.
- C. A client who has a right femur fracture with no weight bearing on the affected leg.
- D. A client who has bilateral knee replacements with partial weight bearing on both legs.
Correct answer: C
Rationale: The correct answer is C because a three-point gait is used when the client can bear full weight on one foot and uses crutches and the uninvolved leg to ambulate. Choices A, B, and D are incorrect because they do not meet the criteria for using a three-point gait. Choice A states that the client can bear full weight on both lower extremities, which does not require a three-point gait. Choice B mentions bilateral leg braces due to paralysis, which would not involve using a three-point gait. Choice D describes a client with bilateral knee replacements with partial weight bearing, which also does not align with the use of a three-point gait.
3. A healthcare professional is assessing a client for signs of anemia. Which of the following findings should the healthcare professional expect?
- A. Increased energy levels
- B. Pale skin
- C. Elevated blood pressure
- D. Decreased heart rate
Correct answer: B
Rationale: Pale skin is a common sign of anemia due to reduced hemoglobin levels, leading to decreased oxygen delivery to tissues. This results in skin pallor. Choices A, C, and D are incorrect. Anemia typically causes fatigue and decreased energy levels (not increased), low blood pressure (not elevated), and tachycardia (increased heart rate) to compensate for the decreased oxygen-carrying capacity of the blood.
4. 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.
5. A nurse is caring for a client prescribed hydroxychloroquine. Which of the following should the nurse monitor?
- A. Liver function tests
- B. Eye exams
- C. Blood glucose levels
- D. Complete blood count
Correct answer: B
Rationale: The correct answer is B: Eye exams. Hydroxychloroquine can cause retinal damage, making it essential for the nurse to monitor the client's eyes regularly for any changes. Monitoring liver function tests (choice A), blood glucose levels (choice C), or complete blood count (choice D) are not directly associated with the potential side effects of hydroxychloroquine.
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