ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is planning care for four clients. Which client is the highest priority?
- A. Client with dry, black eschar on the heel
- B. Client wearing an arm cast and reporting numb fingers
- C. Client with reddened skin around the coccyx
- D. Client with frequent incontinence
Correct answer: B
Rationale: The correct answer is B because numb fingers indicate neurovascular compromise, which can lead to serious complications if not addressed promptly. The priority in this situation is to assess and address any circulation issues affecting the extremity. Choices A, C, and D are of concern but not as immediate as neurovascular compromise, which requires urgent attention to prevent further complications.
2. A public health nurse is developing a list of interventions to address the 3 core functions of public health. What interventions should the nurse include as a part of the assurance function?
- A. Collect data on health trends in the community.
- B. Organize an immunization clinic for at-risk members of the community.
- C. Develop policies to address health disparities.
- D. Conduct research on communicable diseases in the area.
Correct answer: B
Rationale: The correct answer is B: 'Organize an immunization clinic for at-risk members of the community.' The assurance function of public health involves ensuring that essential public health services, like immunizations, are provided to meet public health goals. Choice A, collecting data on health trends, is more aligned with the assessment function of public health. Choice C, developing policies to address health disparities, pertains to the policy development function. Choice D, conducting research on communicable diseases, is related to the research function rather than the assurance function.
3. A nurse is assessing a client who is 24 hours postpartum. Which of the following findings should the nurse report to the healthcare provider?
- A. Uterine fundus is firm and midline
- B. Client's perineal pad is saturated in 15 minutes
- C. Client reports breast tenderness when breastfeeding
- D. Client's temperature is 100.4°F
Correct answer: B
Rationale: A perineal pad saturated in 15 minutes is a sign of excessive postpartum bleeding, which requires immediate medical attention to prevent postpartum hemorrhage. The other findings are normal postpartum occurrences. A firm and midline uterine fundus indicates proper involution, breast tenderness during breastfeeding is common due to engorgement, and a temperature of 100.4°F is considered within the normal range for the postpartum period.
4. A client has developed a pulmonary embolism. Which of the following interventions should the nurse implement first?
- A. Administer oxygen
- B. Prepare the client for a thoracentesis
- C. Elevate the client’s lower extremities
- D. Administer anticoagulant therapy
Correct answer: A
Rationale: Administering oxygen is the priority intervention for a client with a pulmonary embolism. Pulmonary embolism can lead to impaired gas exchange, causing hypoxemia. Administering oxygen helps to maintain adequate oxygenation levels. Thoracentesis is not indicated for a pulmonary embolism, as it is a procedure to remove fluid or air from the pleural space, not a treatment for embolism. Elevating the client's lower extremities is not a priority in the management of a pulmonary embolism. Administering anticoagulant therapy is important in the treatment of pulmonary embolism to prevent further clot formation, but it is not the first intervention. Oxygen administration takes precedence to address the immediate oxygenation needs of the client.
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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