ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN
1. A healthcare professional is preparing to administer a flu vaccine. Which of the following should the healthcare professional verify?
- A. Client's age
- B. Client's allergy to eggs
- C. Client's vaccination history
- D. Client's weight
Correct answer: C
Rationale: The healthcare professional should verify the client's vaccination history to ensure they are due for the flu vaccine. Verifying the client's age (choice A) is important for other vaccines but not specifically for the flu vaccine. While allergy to eggs (choice B) is relevant as the flu vaccine is traditionally produced in eggs, it is not the top priority for verification. The client's weight (choice D) is not directly related to the administration of the flu vaccine.
2. A nurse is performing a newborn assessment and notes a soft, swollen area on the newborn's scalp that does not cross the suture line. Which of the following should the nurse document?
- A. Cephalohematoma
- B. Caput succedaneum
- C. Subdural hematoma
- D. Molding
Correct answer: A
Rationale: The correct answer is A, cephalohematoma. A cephalohematoma is a collection of blood between the periosteum and the skull that does not cross the suture line. It is caused by trauma during birth and typically resolves on its own. Choice B, caput succedaneum, is characterized by diffuse edema over a newborn's scalp that crosses suture lines. Choice C, subdural hematoma, is a more serious condition involving bleeding between the dura mater and the brain. Choice D, molding, refers to the shaping of the fetal head during passage through the birth canal. Therefore, the nurse should document cephalohematoma in this scenario as it aligns with the description of a soft, swollen area on the newborn's scalp that does not cross the suture line.
3. A nurse is caring for a client who is postoperative following a thyroidectomy. The client reports tingling in the fingers and around the mouth. The nurse should anticipate which of the following interventions?
- A. Administer calcium gluconate
- B. Provide a high-protein diet
- C. Administer levothyroxine
- D. Apply a warm compress to the client's neck
Correct answer: A
Rationale: Tingling in the fingers and around the mouth is a sign of hypocalcemia, which can occur after thyroid surgery due to accidental damage to the parathyroid glands. Hypocalcemia is common after thyroidectomy due to potential parathyroid damage. Calcium gluconate is the appropriate intervention to treat hypocalcemia. Providing a high-protein diet or administering levothyroxine are not indicated for hypocalcemia. Applying a warm compress to the client's neck would not address the underlying issue of hypocalcemia.
4. A nurse is providing discharge teaching to a client with heart failure and a prescription for furosemide 20 mg PO twice daily. Which of the following instructions should the nurse include in the teaching?
- A. Monitor for increased blood pressure
- B. Increase intake of high-potassium foods
- C. Expect an increase in swelling in the hands and feet
- D. Take the second dose at bedtime
Correct answer: B
Rationale: The correct answer is B: "Increase intake of high-potassium foods." Furosemide is a loop diuretic that can lead to hypokalemia, a condition characterized by low potassium levels. To prevent this adverse effect, the client should increase their intake of high-potassium foods. Choice A is incorrect because furosemide typically leads to decreased blood pressure, not increased. Choice C is incorrect because furosemide is used to reduce swelling, not increase it. Choice D is incorrect because the second dose of furosemide should be taken in the morning to prevent nocturia.
5. A nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. Which of the following actions should the nurse take first?
- A. Maintain IV access
- B. Obtain the client’s vital signs
- C. Contact the provider
- D. Stop the transfusion
Correct answer: D
Rationale: The correct answer is to stop the transfusion. When a nurse suspects an adverse reaction to a blood transfusion, the priority is to stop the infusion immediately to prevent further harm to the client. Maintaining IV access and obtaining vital signs can be important steps but should come after stopping the transfusion to ensure the client's safety. Contacting the provider is necessary but not the first action to take in this situation. Therefore, the nurse should prioritize stopping the transfusion to address the potential adverse reaction.
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