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. While caring for a client in active labor, a nurse notes late decelerations in the FHR on the external fetal monitor. Which of the following actions should the nurse take first?
- A. Change the client's position
- B. Palpate the uterus to assess for tachysystole
- C. Increase the client's IV infusion rate
- D. Administer oxygen at 10 L/min via nonrebreather mask
Correct answer: A
Rationale: The correct initial action for the nurse to take is to change the client's position. This intervention can alleviate pressure on the umbilical cord, potentially improving fetal oxygenation and addressing the underlying cause of late decelerations. Palpating the uterus to assess for tachysystole or increasing the IV infusion rate are not the first-line interventions for addressing late decelerations. Administering oxygen at a high flow rate via a nonrebreather mask may be necessary but is not the priority action in this situation.
3. A client in respiratory distress who is on oxygen is being cared for by a nurse. What is the most appropriate short-term goal?
- A. Nasal cannula remains in place
- B. Client completes morning care
- C. Client verbalizes breathing improvement after lunch
- D. Client maintains oxygen saturation of 90% during the shift
Correct answer: D
Rationale: The correct answer is D because maintaining oxygen saturation of 90% is a specific, measurable short-term goal that ensures adequate oxygenation. Choice A is not a goal focused on the client's physiological status but rather on the equipment. Choice B is related to activities of daily living and does not address the respiratory distress issue. Choice C is subjective and may not reflect the actual physiological improvement in the client's condition.
4. A client is prescribed furosemide. Which of the following is a potential side effect?
- A. Hyperkalemia
- B. Hypokalemia
- C. Hyponatremia
- D. Hypernatremia
Correct answer: B
Rationale: The correct answer is B: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through urine, causing hypokalemia. Hyperkalemia (choice A) is not a side effect of furosemide. Hyponatremia (choice C) and hypernatremia (choice D) are related to sodium levels rather than potassium, and they are not typically associated with furosemide use.
5. A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?
- A. Redness at the site
- B. Warmth around the site
- C. Edema
- D. Pain at the site
Correct answer: C
Rationale: Edema at the IV site indicates that IV solution has leaked into the extravascular tissue, which is a sign of infiltration. Redness, warmth, and pain at the site are more indicative of phlebitis, not infiltration. Phlebitis is characterized by redness, warmth, and pain along the vein where the IV is placed, while infiltration involves the leaking of IV fluids into the surrounding tissue.
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