ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A healthcare professional is preparing to administer a dose of hydrocodone. Which of the following should the healthcare professional assess first?
- A. Respiratory rate
- B. Blood pressure
- C. Pain level
- D. Heart rate
Correct answer: A
Rationale: When administering hydrocodone, a healthcare professional should assess the respiratory rate first because hydrocodone is an opioid that can lead to respiratory depression. Monitoring the respiratory rate helps to detect any signs of respiratory distress or depression early on. Assessing blood pressure, pain level, or heart rate is also important but not the priority when administering hydrocodone, as the risk of respiratory depression is a more critical concern.
2. A client scheduled for an electroencephalogram (EEG) is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?
- A. “I should not wash my hair before the procedure.”
- B. “I will be given a sedative 1 hour before the procedure.”
- C. “I should refrain from eating before the procedure.”
- D. “I will be exposed to flashes of light during the procedure.”
Correct answer: D
Rationale: The correct answer is D. During an electroencephalogram (EEG), flashes of light or patterns are often used to stimulate the brain and provoke responses, helping to assess brain activity and the potential for seizures. Choices A, B, and C are incorrect because washing the hair, receiving a sedative, and refraining from eating are not usually related to EEG procedures and do not reflect understanding of the teaching provided by the nurse.
3. A nurse receives a change-of-shift report. Which of the following clients should the nurse attend to first?
- A. A client who reports tingling in the fingers following a thyroidectomy
- B. A client who has dark, foul-smelling urine with a urine output of 320 mL in the last 8 hr
- C. A client who is in a long leg cast and reports cool feet bilaterally
- D. A client who has a productive cough and an oral temperature of 36°C (96.8°F)
Correct answer: C
Rationale: The correct answer is C. Cool feet bilaterally in a client with a long leg cast may indicate compromised circulation, which is a medical emergency that requires immediate intervention. Choices A, B, and D do not present immediate life-threatening conditions. Tingling in the fingers following a thyroidectomy may indicate hypocalcemia but does not require immediate attention. Dark, foul-smelling urine with decreased urine output indicates a possible urinary tract infection or dehydration but can be addressed after attending to the client with compromised circulation. A productive cough and a normal oral temperature do not suggest an urgent condition compared to compromised circulation in a client with a long leg cast.
4. A nurse is caring for a client who is in labor and has a diagnosis of group B streptococcus ß-hemolytic infection. Which of the following medications should the nurse plan to administer?
- A. Ampicillin
- B. Azithromycin
- C. Ceftriaxone
- D. Acyclovir
Correct answer: A
Rationale: Ampicillin is the correct choice for treating group B streptococcus infections in pregnant women during labor to prevent neonatal infection. Group B streptococcus is commonly treated with penicillin or ampicillin; therefore, choices B, C, and D are incorrect. Azithromycin is not the first-line treatment for group B streptococcus. Ceftriaxone is not the preferred antibiotic for this infection during labor. Acyclovir is an antiviral medication used for herpes simplex virus infections, not bacterial infections like group B streptococcus.
5. A healthcare professional is assessing a client for signs of fluid overload. Which of the following findings should the healthcare professional look for?
- A. Weight loss
- B. Decreased blood pressure
- C. Edema
- D. Increased urine output
Correct answer: C
Rationale: Edema is a common sign of fluid overload. When the body retains more fluid than it excretes, it can lead to edema, which is swelling caused by excess fluid trapped in body tissues. Weight gain, not weight loss, is typically associated with fluid overload due to the retained fluids. Decreased blood pressure is more commonly associated with dehydration rather than fluid overload. Increased urine output is a sign of the body trying to eliminate excess fluids, which is contrary to the signs of fluid overload.
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