ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A healthcare professional is preparing to administer heparin 8,000 units subcutaneously every eight hrs. The amount available is heparin injection 10,000 units/mL. How many milliliters should the healthcare professional administer per dose?
- A. 0.7 mL
- B. 0.8 mL
- C. 1.0 mL
- D. 1.2 mL
Correct answer: B
Rationale: Calculation: 8000 units / 10,000 units per mL = 0.8 mL. To correctly administer the prescribed dose of 8000 units, the healthcare professional should draw up 0.8 mL from the 10,000 units/mL vial. Options A, C, and D are incorrect as they do not accurately reflect the calculation based on the available concentration of heparin.
2. A healthcare professional is assessing a client for signs of anaphylaxis. Which of the following findings should the healthcare professional look for?
- A. Bradycardia
- B. Hypotension
- C. Increased appetite
- D. Decreased respiratory rate
Correct answer: B
Rationale: Hypotension is a critical sign of anaphylaxis. During anaphylaxis, there is a widespread vasodilation leading to a drop in blood pressure, which manifests as hypotension. This can be accompanied by other symptoms such as swelling, difficulty breathing, hives, and itching. Bradycardia (choice A) is not typically associated with anaphylaxis; instead, tachycardia is more common due to the body's response to the allergic reaction. Increased appetite (choice C) is unrelated to anaphylaxis, as individuals experiencing anaphylaxis often feel unwell and may have nausea or vomiting. Decreased respiratory rate (choice D) is also not a typical finding in anaphylaxis; instead, respiratory distress and wheezing are more commonly observed.
3. Which of the following interventions is most appropriate for a client with hyperemesis gravidarum?
- A. Encourage high-calorie meals
- B. Administer intravenous fluids
- C. Provide frequent small meals
- D. Limit fluid intake
Correct answer: B
Rationale: The correct answer is B: Administer intravenous fluids. Hyperemesis gravidarum is severe, persistent nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. The priority intervention is to administer intravenous fluids to maintain hydration. Encouraging high-calorie meals (Choice A) may exacerbate symptoms due to increased gastric stimulation. Providing frequent small meals (Choice C) may not be effective in severe cases where continuous vomiting occurs. Limiting fluid intake (Choice D) is contraindicated in hyperemesis gravidarum as dehydration is a significant concern.
4. When planning to discharge a client receiving home oxygen therapy, which of the following instructions should the nurse include in the discharge teaching?
- A. Ensure that electrical cords are not frayed
- B. Keep oxygen tanks in a horizontal position
- C. Store extra oxygen tanks in a closed closet
- D. Apply petroleum-based gel to the inside of the nostrils
Correct answer: A
Rationale: The correct answer is to ensure that electrical cords are not frayed. Frayed electrical cords pose a fire hazard when oxygen is in use. Keeping oxygen tanks in a horizontal position (Choice B) is important to prevent leaks but is not the priority compared to fire safety. Storing extra oxygen tanks in a closed closet (Choice C) is also important but not as immediate as preventing fire hazards. Applying petroleum-based gel to the inside of the nostrils (Choice D) is unrelated to oxygen therapy safety and is not recommended.
5. A client who has been prescribed oral contraception receives education from a nurse. Which of the following client statements indicates a need for further education?
- A. If I miss one pill, I'll take it as soon as possible
- B. If I miss two pills, I'll double up for two days
- C. If I miss three pills, I'll double up each day until back on schedule
- D. I'll use an alternative form of contraception if I miss more than two pills
Correct answer: C
Rationale: The correct course of action after missing oral contraceptive pills depends on how many pills are missed. If three pills are missed, the client should not 'double up' but rather follow the manufacturer's instructions and use an alternative form of contraception until the next cycle. Taking too many pills at once increases the risk of side effects without restoring contraceptive protection. Choices A, B, and D demonstrate understanding of the correct actions to take after missing a pill or two, emphasizing the importance of not doubling up but following specific guidelines to maintain effectiveness and safety.
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