ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A nurse is preparing to administer a dose of furosemide. Which of the following should the nurse do before administration?
- A. Check potassium levels
- B. Assess blood glucose levels
- C. Monitor respiratory rate
- D. Administer with food
Correct answer: A
Rationale: The correct answer is to check potassium levels before administering furosemide. Furosemide is a diuretic that can cause hypokalemia (low potassium levels) as a side effect. Monitoring potassium levels is crucial to prevent potential complications related to electrolyte imbalance. Assessing blood glucose levels (choice B) is not directly related to furosemide administration. Monitoring respiratory rate (choice C) is important in certain situations, but it is not the priority before administering furosemide. Administering furosemide with food (choice D) is not a requirement as it can be administered regardless of meals.
2. A nurse is caring for a client who has deep vein thrombosis (DVT) of the left lower extremity. Which of the following actions should the nurse take?
- A. Position the client with the affected extremity higher than the heart
- B. Administer acetaminophen for pain
- C. Massage the affected extremity every 4 hours
- D. Withhold heparin IV infusion
Correct answer: D
Rationale: The correct answer is to withhold heparin IV infusion. The nurse should withhold heparin if there are signs of complications, such as bleeding, or if there are contraindications to continuing anticoagulation therapy. Positioning the client with the affected extremity higher than the heart helps reduce swelling and improve blood flow. Administering acetaminophen for pain management can be appropriate, but it is not the priority in this situation. Massaging the affected extremity can dislodge the clot and lead to serious complications, so it should be avoided.
3. A nurse is teaching a client about the use of alendronate. Which of the following should be included in the teaching?
- A. Take it with food
- B. Sit upright for at least 30 minutes after taking it
- C. It can be taken at bedtime
- D. It is safe to take with antacids
Correct answer: B
Rationale: The correct answer is B: 'Sit upright for at least 30 minutes after taking it.' Alendronate can cause esophageal irritation and to reduce the risk of this side effect, clients should be instructed to sit upright for at least 30 minutes after administration. Choice A is incorrect as alendronate should be taken on an empty stomach, usually in the morning, at least 30 minutes before the first food, beverage, or medication of the day. Choice C is incorrect because alendronate should not be taken at bedtime, as the client should remain upright for at least 30 minutes after taking it. Choice D is incorrect as antacids can interfere with the absorption of alendronate, so they should not be taken together.
4. A nurse is planning care for a patient who follows the Mormon belief system. What modifications should the nurse include to meet Mormon dietary practices?
- A. Offer only vegetarian meal options.
- B. Offer non-caffeinated beverage options.
- C. Offer kosher meals.
- D. Limit meat to only fish and poultry.
Correct answer: B
Rationale: The correct answer is B: Offer non-caffeinated beverage options. Mormons avoid caffeinated beverages, so providing non-caffeinated options aligns with their religious practices. Choice A is incorrect because offering only vegetarian meal options is not a specific requirement of the Mormon dietary practices. Choice C is incorrect as kosher meals are associated with Jewish dietary laws, not specific to the Mormon belief system. Choice D is incorrect as limiting meat to only fish and poultry is not a specific dietary requirement for Mormons.
5. When assessing a client with a small bowel obstruction, what finding should a nurse expect?
- A. Significant abdominal distention
- B. Large bowel movements
- C. High-pitched bowel sounds
- D. Copious vomiting
Correct answer: C
Rationale: High-pitched bowel sounds are often heard early in a small bowel obstruction due to increased peristalsis as the bowel tries to overcome the blockage. Choices A, B, and D are incorrect. Abdominal distention is more commonly associated with large bowel obstructions, while large bowel movements and copious vomiting are not typical findings in small bowel obstructions.
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