ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A
1. A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?
- A. Contact provider if the cord turns black
- B. Clean the base of the cord with hydrogen peroxide daily
- C. Keep the cord dry until it falls off
- D. The cord stump will fall off in ten days
Correct answer: C
Rationale: The correct instruction to include in the teaching for cord care is to keep the cord dry until it falls off naturally. This helps prevent infection, as the cord typically falls off in 10-14 days, not within five days. Instructing the parent to contact the provider if the cord turns black (Choice A) is important to monitor for signs of infection. Cleaning the base of the cord with hydrogen peroxide daily (Choice B) is not recommended as it can delay healing. Stating that the cord stump will fall off in ten days (Choice D) provides a more accurate timeframe compared to the initial estimation of five days.
2. A client is receiving vancomycin. Which of the following should the nurse monitor?
- A. Blood glucose levels
- B. Serum creatinine
- C. INR levels
- D. Liver function tests
Correct answer: B
Rationale: The correct answer is B: Serum creatinine. Vancomycin is known to be nephrotoxic, meaning it can cause kidney damage. Monitoring serum creatinine levels is essential to assess kidney function and detect any signs of nephrotoxicity. Blood glucose levels (choice A) are not directly affected by vancomycin. INR levels (choice C) are typically monitored for clients on anticoagulants, not vancomycin. Liver function tests (choice D) are not primarily affected by vancomycin use; kidney function is of greater concern.
3. A nurse is teaching a client about the use of levetiracetam. Which of the following should be included in the teaching?
- A. It can cause weight loss
- B. Monitor for mood changes
- C. It is an over-the-counter medication
- D. It has no side effects
Correct answer: B
Rationale: The correct answer is B. Levetiracetam can cause mood changes and behavioral side effects, so clients should be monitored for these effects. Choice A is incorrect because levetiracetam is not typically associated with weight loss. Choice C is incorrect as levetiracetam is a prescription medication, not available over the counter. Choice D is incorrect as all medications, including levetiracetam, have potential side effects.
4. A nurse is preparing to administer a dose of losartan. Which of the following should the nurse assess first?
- A. Blood pressure
- B. Heart rate
- C. Serum potassium
- D. Liver function
Correct answer: A
Rationale: The correct answer is to assess blood pressure first. Losartan is an angiotensin receptor blocker used to lower blood pressure. Assessing the patient's blood pressure before administering losartan is crucial to ensure it is not already too low, which could lead to hypotension. Assessing heart rate (choice B) is important but not the priority when administering losartan. Serum potassium levels (choice C) and liver function (choice D) are also important assessments, but they are not the primary concern before administering losartan.
5. A nurse is teaching a group of assistive personnel (AP) about the expected integumentary changes in older adults. Which should the nurse include?
- A. Increase in elasticity
- B. Decrease in pigmentation
- C. Decrease in elasticity
- D. Increase in moisture levels
Correct answer: C
Rationale: The correct answer is C: 'Decrease in elasticity.' As individuals age, they typically experience a decrease in skin elasticity, leading to sagging skin and increased wrinkles. This change in elasticity can contribute to various skin-related issues such as pressure ulcers and delayed wound healing. Choices A, B, and D are incorrect because older adults do not experience an increase in elasticity or moisture levels, and while there may be changes in pigmentation, the primary change related to aging in the integumentary system is a decrease in elasticity.
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