ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A nurse is preparing to administer prochlorperazine 2.5 mg IV. Available is prochlorperazine injection 5 mg/mL. How many mL should the nurse administer?
- A. 0.2 mL
- B. 0.5 mL
- C. 1.0 mL
- D. 1.5 mL
Correct answer: B
Rationale: To determine the volume of prochlorperazine to administer, divide the prescribed dose (2.5 mg) by the concentration of the medication (5 mg/mL). This calculation results in 0.5 mL. Therefore, the nurse should administer 0.5 mL to deliver the correct dose. Choice A (0.2 mL) is incorrect as it miscalculates the dosage. Choices C (1.0 mL) and D (1.5 mL) are also incorrect as they do not accurately reflect the calculated volume needed for the dose.
2. A client is receiving digoxin therapy. Which of the following should the nurse monitor?
- A. Liver function
- B. Serum electrolytes
- C. Blood pressure
- D. All of the above
Correct answer: D
Rationale: When a client is receiving digoxin therapy, it is crucial for the nurse to monitor liver function, serum electrolytes (especially potassium levels), and blood pressure. Digoxin is known to affect the heart's electrical activity and can lead to toxic effects if not managed properly. Monitoring liver function helps to assess the drug's metabolism and excretion. Checking serum electrolytes, especially potassium, is essential because digoxin toxicity can be exacerbated by electrolyte imbalances, particularly hypokalemia. Monitoring blood pressure is necessary because digoxin can influence cardiac contractility and heart rate, potentially affecting blood pressure. Therefore, monitoring all these parameters is vital to ensure the client's safety and therapeutic effectiveness of digoxin. Choices A, B, and C are incorrect because monitoring only one or two of these parameters may not provide a comprehensive assessment of the client's response to digoxin therapy.
3. A nurse is caring for a client who has peptic ulcer disease (PUD) and is prescribed sucralfate. Which of the following instructions should the nurse include in the teaching?
- A. Take sucralfate with an antacid.
- B. Take sucralfate 1 hour before meals.
- C. Take sucralfate with food.
- D. Take sucralfate at bedtime only.
Correct answer: B
Rationale: The correct answer is B. Sucralfate should be taken on an empty stomach, 1 hour before meals. This timing allows sucralfate to form a protective barrier over the ulcer, enhancing healing. Choice A is incorrect because sucralfate should not be taken with an antacid. Choice C is incorrect because sucralfate should not be taken with food. Choice D is incorrect because sucralfate should not be taken at bedtime only; it is best absorbed on an empty stomach.
4. A client is being taught how to use a diaphragm for contraception. Which of the following client statements indicate an understanding of the teaching?
- A. I will leave the diaphragm in place for at least 6 hours after intercourse.
- B. I will remove the diaphragm by catching the rim below the dome with my finger.
- C. I will not apply mineral oil on the diaphragm.
- D. I will place 2 teaspoons of spermicide on the inside of the diaphragm before inserting it.
Correct answer: D
Rationale: The correct answer is D. The client should place spermicide inside the diaphragm before insertion to enhance contraceptive effectiveness. It is recommended to leave the diaphragm in place for at least 6 hours after intercourse, but not more than 24 hours. Choice A is incorrect because the diaphragm should be left in place for at least 6 hours, not 4 hours. Choice B is incorrect as the diaphragm should be removed by hooking the rim below the dome, not above. Choice C is incorrect because mineral oil should not be used with the diaphragm as it can weaken the latex.
5. A nurse is assessing a client for signs of heart failure. Which of the following findings should the nurse monitor?
- A. Decreased heart rate
- B. Peripheral edema
- C. Increased energy levels
- D. Hyperglycemia
Correct answer: B
Rationale: The correct answer is B: Peripheral edema. Peripheral edema, the accumulation of fluid causing swelling in the extremities, is a classic sign of heart failure due to fluid overload. This occurs because the heart's reduced pumping efficiency leads to fluid backup in the circulatory system. Choices A, C, and D are incorrect. Decreased heart rate is not typically associated with heart failure; instead, tachycardia or an increased heart rate may be observed. Increased energy levels are not an expected finding in heart failure, as this condition often causes fatigue and weakness. Hyperglycemia is not a direct sign of heart failure; however, it can be present in individuals with uncontrolled diabetes or as a result of certain treatments, but it is not a specific indicator of heart failure.
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