ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A nurse is providing education on the use of calcium carbonate. Which of the following should be included?
- A. It can cause hypocalcemia
- B. Monitor for constipation
- C. It can be taken anytime
- D. It is a prescription medication
Correct answer: B
Rationale: The correct answer is B: 'Monitor for constipation.' Calcium carbonate can cause constipation as a side effect. Educating clients on dietary adjustments, such as increasing fluid intake and fiber consumption, can help alleviate this issue. Choice A is incorrect because calcium carbonate supplementation is used to treat hypocalcemia, not cause it. Choice C is incorrect because calcium carbonate should be taken with food for optimal absorption. Choice D is incorrect because calcium carbonate is available over the counter, not as a prescription medication.
2. A client with schizophrenia is experiencing auditory hallucinations. Which of the following actions should the nurse take first?
- A. Encourage the client to listen to music
- B. Ask the client what the voices are saying
- C. Provide the client with a distraction
- D. Administer an antipsychotic medication
Correct answer: B
Rationale: Asking the client what the voices are saying is the priority action as it helps assess the content of the hallucinations. This assessment is crucial to determine if the client is at risk of harm to themselves or others. Encouraging the client to listen to music or providing a distraction may not address the underlying issues related to the hallucinations. Administering antipsychotic medication, although important, should come after a thorough assessment of the hallucinations to ensure the right medication and dosage are provided.
3. A healthcare professional is assessing a client with deep vein thrombosis (DVT). Which of the following interventions should the healthcare professional include in the plan of care?
- A. Apply ice packs to the affected extremity.
- B. Encourage ambulation every hour.
- C. Elevate the affected leg when in bed.
- D. Massage the affected area to improve circulation.
Correct answer: C
Rationale: Elevating the affected leg is a crucial intervention in the care of a client with deep vein thrombosis (DVT). This position helps reduce swelling and promotes venous return, which can alleviate symptoms associated with DVT. Applying ice packs (Choice A) may worsen the condition by causing vasoconstriction. Encouraging ambulation (Choice B) can dislodge the clot and lead to fatal complications. Massaging the affected area (Choice D) can also dislodge the clot and is contraindicated in DVT.
4. A nurse is caring for a client who sprained his ankle 12 hours ago. Which of the following provider prescriptions should the nurse question?
- A. Elevate the affected extremity on two pillows
- B. Apply heat to the affected extremity for 45 minutes
- C. Wrap the extremity with a compression dressing
- D. Assess sensation, movement, and pulse every 4 hours
Correct answer: B
Rationale: The nurse should question the prescription to apply heat to the affected extremity for 45 minutes. Heat should not be applied in the first 48 hours after an acute injury, as it can increase swelling. Cold therapy is more appropriate initially. Choices A, C, and D are appropriate actions in the care of a client with a sprained ankle. Elevating the affected extremity helps reduce swelling, wrapping it with a compression dressing provides support, and assessing sensation, movement, and pulse every 4 hours is important to monitor for complications.
5. A nurse is caring for a client receiving heparin. Which of the following should the nurse monitor?
- A. INR levels
- B. APTT levels
- C. Blood glucose levels
- D. Liver function tests
Correct answer: B
Rationale: Heparin therapy requires monitoring of activated partial thromboplastin time (APTT) to ensure therapeutic levels. APTT reflects the intrinsic pathway of the clotting cascade and is used to assess the effectiveness and safety of heparin therapy. Monitoring INR levels is more relevant for assessing warfarin therapy, not heparin. Blood glucose levels are monitored for clients with diabetes or those on medications affecting glucose levels. Liver function tests are used to assess liver health and are not directly related to monitoring heparin therapy.
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