ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A nurse is preparing to perform a sterile dressing change for a client with a surgical wound. Which action should the nurse take to prevent contamination during the dressing change?
- A. Proceed with the dressing change
- B. Restart the procedure if the sterile solution splashes onto the sterile field
- C. Continue without concern for minor splashes
- D. Delegate the task to another nurse
Correct answer: B
Rationale: The correct action for the nurse to take to prevent contamination during a sterile dressing change is to restart the procedure if the sterile solution splashes onto the sterile field. Any contamination of the sterile field compromises the aseptic technique and increases the risk of infection for the client. Therefore, it is crucial to maintain the sterility of the field throughout the procedure. Choices A, C, and D are incorrect because proceeding with the dressing change, continuing without concern for minor splashes, or delegating the task to another nurse would all compromise the sterility of the procedure and increase the risk of infection for the client.
2. A client who has a new prescription for simvastatin is receiving teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will take this medication in the morning.
- B. I should avoid drinking grapefruit juice while taking this medication.
- C. I should expect my cholesterol levels to increase initially.
- D. I will need to have my kidney function checked every 3 months.
Correct answer: B
Rationale: The correct answer is B. Grapefruit juice can increase the risk of toxicity with simvastatin, so clients should avoid consuming it while on the medication. Choice A is incorrect because the timing of medication administration should be based on healthcare provider instructions. Choice C is incorrect because simvastatin is prescribed to lower cholesterol levels. Choice D is incorrect as monitoring kidney function is not specifically related to simvastatin therapy.
3. A client with lactose intolerance needs to increase calcium intake. Which food should the nurse recommend?
- A. Spinach
- B. Peanut butter
- C. Ground beef
- D. Carrots
Correct answer: A
Rationale: Spinach is a suitable choice to recommend for increasing calcium intake to a client with lactose intolerance. Spinach is a good non-dairy source of calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium. Peanut butter is high in protein and fats, ground beef is a source of protein and iron, and carrots are rich in vitamin A and fiber, but none of these choices provide a substantial amount of calcium.
4. A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?
- A. A client who is able to bear full weight on both lower extremities.
- B. A client who has bilateral leg braces due to paralysis of the lower extremities.
- C. A client who has a right femur fracture with no weight bearing on the affected leg.
- D. A client who has bilateral knee replacements with partial weight bearing on both legs.
Correct answer: C
Rationale: The correct answer is C because a three-point gait is used when the client can bear full weight on one foot and uses crutches and the uninvolved leg to ambulate. Choices A, B, and D are incorrect because they do not meet the criteria for using a three-point gait. Choice A states that the client can bear full weight on both lower extremities, which does not require a three-point gait. Choice B mentions bilateral leg braces due to paralysis, which would not involve using a three-point gait. Choice D describes a client with bilateral knee replacements with partial weight bearing, which also does not align with the use of a three-point gait.
5. A client with hypertension is being taught about dietary modifications by a nurse. Which of the following food choices should the nurse recommend?
- A. Canned tomato soup
- B. Baked chicken breast
- C. Processed cheese
- D. Pickled vegetables
Correct answer: B
Rationale: The correct answer is Baked chicken breast. It is low in sodium and a healthy option for clients with hypertension. Canned tomato soup and processed cheese are typically high in sodium, which is not recommended for individuals with hypertension. Pickled vegetables are also high in sodium and should be avoided in a hypertension-friendly diet.
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