ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A client with staphylococcus epidermidis is prescribed vancomycin. Identify the adverse effect associated with this antibiotic therapy.
- A. Hepatotoxicity
- B. Constipation
- C. Infusion reaction
- D. Immunosuppression
Correct answer: C
Rationale: The correct adverse effect associated with vancomycin therapy is an infusion reaction, known as Red Man Syndrome. This reaction presents with rashes, flushing, tachycardia, and hypotension. It is essential to administer vancomycin over at least 60 minutes to prevent these symptoms. Hepatotoxicity, constipation, and immunosuppression are not commonly associated with vancomycin use. Ototoxicity and renal toxicity are significant risks with prolonged vancomycin therapy.
2. A client is found on the floor of their room experiencing a seizure. Which action is the nurse's priority?
- A. Restrain the client
- B. Place the client on their side with their head forward
- C. Perform a neurological assessment
- D. Monitor the client's vitals every 2 minutes
Correct answer: B
Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration of fluids or secretions. Restraint should never be used during a seizure as it can cause harm to the client. Performing a neurological assessment is important but not the immediate priority during an active seizure. While monitoring vitals is essential, ensuring the client's airway is clear takes precedence.
3. A nurse is preparing to administer IV furosemide. Which of the following should the nurse monitor for during the infusion?
- A. Increased urinary output
- B. Ototoxicity
- C. Hypokalemia
- D. Hypoglycemia
Correct answer: C
Rationale: The correct answer is C: Hypokalemia. Furosemide is a loop diuretic that works by increasing the excretion of water and electrolytes, particularly potassium. Therefore, the nurse should monitor for hypokalemia, as low potassium levels can lead to various complications such as cardiac dysrhythmias. Choice A, increased urinary output, is an expected effect of furosemide due to its diuretic action but is not a side effect needing monitoring. Ototoxicity (Choice B) is a potential adverse effect of other medications like aminoglycoside antibiotics, not furosemide. Hypoglycemia (Choice D) is not a common side effect associated with furosemide administration.
4. A healthcare provider is discussing recommendations for daily nutrient intake during pregnancy with a client who is at 10 weeks of gestation. For which of the following nutrients should the healthcare provider instruct the client to increase intake during pregnancy?
- A. Vitamin E
- B. Vitamin D
- C. Fiber
- D. Calcium
Correct answer: D
Rationale: The correct answer is D: Calcium. During pregnancy, it is essential to increase calcium intake as it is crucial for fetal bone development and to prevent maternal bone loss. Adequate calcium supports the increased needs of both the mother and the developing baby. Vitamin E, Vitamin D, and fiber are also important nutrients, but the specific nutrient that needs to be increased during pregnancy for bone development is calcium. Vitamin E is an antioxidant that plays a role in protecting cells from damage, Vitamin D helps with calcium absorption and bone health, and fiber is important for digestive health but does not specifically need to be increased during pregnancy for bone development.
5. A nurse is caring for a client who has been prescribed furosemide. Which of the following foods should the nurse encourage the client to include in their diet?
- A. Table salt
- B. Egg yolks
- C. White wine
- D. Oranges
Correct answer: D
Rationale: Furosemide is a potassium-wasting diuretic, so clients should consume potassium-rich foods like oranges to prevent hypokalemia. Oranges are a good source of potassium. Table salt, egg yolks, and white wine do not provide significant amounts of potassium and are not beneficial for a client taking furosemide.
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