ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN
1. A nurse is providing education on the use of aspirin. Which of the following should be included?
- A. It can increase the risk of bleeding
- B. It is safe to give to children
- C. It should be taken on an empty stomach
- D. It has no side effects
Correct answer: A
Rationale: The correct answer is A: 'It can increase the risk of bleeding.' Aspirin is known to have antiplatelet effects and can increase the risk of bleeding, especially if taken in high doses or for prolonged periods. Choice B is incorrect because aspirin is not safe for children due to the risk of Reye's syndrome. Choice C is incorrect because aspirin should be taken with food to minimize gastrointestinal side effects. Choice D is incorrect because aspirin, like any medication, can have side effects, such as gastrointestinal bleeding, ulcers, or allergic reactions.
2. 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.
3. A healthcare provider is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the healthcare provider expect?
- A. Hypotonia
- B. Moderate tremors of the extremities
- C. Axillary temperature 36.1°C (96.9°F)
- D. Excessive crying
Correct answer: B
Rationale: The correct answer is B: Moderate tremors of the extremities. In newborns experiencing opioid withdrawals, moderate tremors of the extremities are a common sign. Other signs of opioid withdrawal in newborns may include irritability, feeding difficulties, and gastrointestinal disturbances. Choice A, hypotonia, is not typically associated with opioid withdrawal in newborns. Choice C, an axillary temperature of 36.1°C (96.9°F), falls within the normal range for newborns and is not specifically indicative of opioid withdrawal. Choice D, excessive crying, is not a typical sign of opioid withdrawal in newborns.
4. In the nursing process, the evaluation phase is used to determine:
- A. Value of the nursing intervention
- B. Accuracy of problem identification
- C. Quality of the plan of care
- D. Degree of outcome achievement
Correct answer: D
Rationale: The evaluation phase of the nursing process is used to determine the degree of outcome achievement. It assesses whether the goals and outcomes set during the planning phase were met. Choice A is incorrect because it focuses on the worth of the intervention rather than the achievement of outcomes. Choice B is incorrect as it pertains to the assessment phase where problems are identified. Choice C is incorrect as it refers to the planning phase where the care plan is developed, not evaluated.
5. A nurse is assessing a client for signs of allergic reaction. Which of the following should the nurse look for?
- A. Fever
- B. Rash
- C. Fatigue
- D. Increased appetite
Correct answer: B
Rationale: Correct! When assessing a client for signs of an allergic reaction, a nurse should look for a rash. A rash is a common manifestation of an allergic response, such as contact dermatitis or hives. It is important to recognize and assess rashes promptly as they can indicate an allergic reaction.\nOption A, fever, is not typically a primary sign of an allergic reaction but may occur in severe cases. Option C, fatigue, is a general symptom and not specific to allergic reactions. Option D, increased appetite, is not a common sign of an allergic reaction and is more likely related to other conditions or factors.
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