ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is planning care for a newly admitted adolescent with bacterial meningitis. What intervention should the nurse include?
- A. Initiate droplet precautions
- B. Assist the client to a supine position
- C. Perform a Glasgow Coma Scale every 24 hours
- D. Recommend prophylactic acyclovir for the client's family
Correct answer: A
Rationale: The correct intervention for a newly admitted adolescent with bacterial meningitis is to initiate droplet precautions. Bacterial meningitis is highly contagious, and droplet precautions are necessary to prevent the spread of infection. Assisting the client to a supine position (Choice B) is not directly related to managing bacterial meningitis. Performing a Glasgow Coma Scale every 24 hours (Choice C) may be important to assess the client's neurological status but is not the priority intervention in preventing the spread of infection. Recommending prophylactic acyclovir for the client's family (Choice D) is not a standard practice in the care of a patient with bacterial meningitis.
2. A nurse is caring for a client recovering from bowel surgery who has a nasogastric (NG) tube connected to low intermittent suction. Which of the following assessment findings should indicate to the nurse that the NG tube may not be functioning properly?
- A. Drainage fluid is greenish-yellow
- B. Aspirate pH of 3
- C. Abdominal rigidity
- D. Air bubbles noted in the NG tube
Correct answer: C
Rationale: Abdominal rigidity can indicate a serious complication, such as a blockage or infection, requiring immediate intervention to determine if the NG tube is functioning properly. Choices A, B, and D are not indicative of a malfunctioning NG tube. Greenish-yellow drainage fluid may be normal, an aspirate pH of 3 is within the expected range for gastric contents, and air bubbles in the NG tube are not abnormal as long as they are moving.
3. A client with hypertension is being taught about dietary modifications by a nurse. Which of the following food choices should the nurse recommend?
- A. Canned tomato soup
- B. Baked chicken breast
- C. Processed cheese
- D. Pickled vegetables
Correct answer: B
Rationale: The correct answer is Baked chicken breast. It is low in sodium and a healthy option for clients with hypertension. Canned tomato soup and processed cheese are typically high in sodium, which is not recommended for individuals with hypertension. Pickled vegetables are also high in sodium and should be avoided in a hypertension-friendly diet.
4. A nurse is teaching a client about the use of clopidogrel. Which of the following should be included?
- A. It is an anticoagulant
- B. Monitor for signs of bleeding
- C. It can be stopped abruptly
- D. Avoid foods rich in vitamin K
Correct answer: B
Rationale: The correct answer is B: 'Monitor for signs of bleeding.' Clopidogrel is an antiplatelet medication, not an anticoagulant. Clients taking clopidogrel should be monitored for signs of bleeding due to its antiplatelet effects. Choice A is incorrect because clopidogrel is not an anticoagulant. Choice C is incorrect as clopidogrel should not be stopped abruptly but as directed by a healthcare provider. Choice D is irrelevant since foods rich in vitamin K are more of a concern with anticoagulant medications like warfarin, not antiplatelet medications like clopidogrel.
5. A client with a history of urinary tract infections (UTIs) is being cared for by a nurse. Which of the following instructions should the nurse provide to prevent future infections?
- A. Wipe from front to back after urination
- B. Drink 2-3 liters of water per day
- C. Avoid holding urine for long periods
- D. Wear loose-fitting underwear
Correct answer: B
Rationale: The correct answer is to advise the client to drink 2-3 liters of water per day. Adequate hydration helps flush bacteria from the urinary tract, reducing the risk of UTIs. Choice A is incorrect because wiping from front to back is the appropriate technique to prevent the spread of bacteria from the rectal area to the urethra. Choice C is incorrect as holding urine for long periods can contribute to UTIs by allowing bacteria to grow in the bladder. Choice D is incorrect as wearing loose-fitting underwear is recommended to allow air circulation and prevent moisture buildup, reducing the risk of UTIs.
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