ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 B
1. A healthcare provider is providing education on the use of clozapine. Which of the following should be included?
- A. Monitor for agranulocytosis
- B. It is a first-line treatment
- C. It can cause significant weight loss
- D. It has no risk for metabolic syndrome
Correct answer: A
Rationale: Correct Answer: A nurse should include monitoring for agranulocytosis when educating a patient about clozapine. Clozapine is known to cause agranulocytosis, a potentially life-threatening decrease in white blood cells. This adverse effect requires close monitoring to detect it early. Choices B, C, and D are incorrect because clozapine is not a first-line treatment for most conditions, it is more commonly associated with weight gain rather than weight loss, and it is known to have a risk for metabolic syndrome.
2. A nurse is teaching postoperative care to the parents of a toddler following a cleft palate repair. Which of the following should be included in the teaching?
- A. Provide an orthodontic pacifier for comfort
- B. Offer fluids using a straw
- C. Cleanse the suture line with a cotton-tip swab
- D. Remove elbow splints periodically to perform range of motion
Correct answer: D
Rationale: The correct answer is D. Elbow splints are utilized to prevent the child from touching the surgical site. However, it is essential to remove them periodically to conduct range-of-motion exercises to prevent joint stiffness. Choices A, B, and C are incorrect because providing an orthodontic pacifier, offering fluids using a straw, and cleansing the suture line with a cotton-tip swab are not directly related to postoperative care following a cleft palate repair.
3. A nurse is assessing a client who reports chest pain. Which of the following findings should cause the nurse to suspect a myocardial infarction?
- A. Pain improves with rest
- B. Pain radiates to the left arm.
- C. Pain worsens with deep breathing.
- D. Pain is relieved by antacids.
Correct answer: B
Rationale: The correct answer is B. Radiating pain, especially to the left arm, is a classic sign of myocardial infarction. Pain that radiates to the left arm indicates cardiac involvement, making it a significant finding. Choices A, C, and D are incorrect because chest pain that improves with rest, worsens with deep breathing, or is relieved by antacids is less likely to be associated with a myocardial infarction.
4. A client with a cystocele is encouraged to exercise to strengthen pelvic floor muscles and prevent pelvic organ prolapse. What exercise will the client need to perform?
- A. Kegel exercises
- B. Isometric exercises
- C. Circumduction exercises
- D. Uterine extension exercises
Correct answer: A
Rationale: Corrected Rationale: The client with a cystocele should perform Kegel exercises to strengthen the pelvic floor muscles, reducing the risk of pelvic organ prolapse and stress urinary incontinence. Kegel exercises specifically target the muscles that support the pelvic organs. Isometric exercises focus on static muscle contractions and may not be as effective as Kegel exercises for strengthening the pelvic floor. Circumduction exercises involve circular movements at joints and are not specific to pelvic floor muscle strengthening. Uterine extension exercises do not directly target the pelvic floor muscles and are not indicated for cystocele management.
5. A nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. Which of the following actions should the nurse take first?
- A. Maintain IV access
- B. Obtain the client’s vital signs
- C. Contact the provider
- D. Stop the transfusion
Correct answer: D
Rationale: The correct answer is to stop the transfusion. When a nurse suspects an adverse reaction to a blood transfusion, the priority is to stop the infusion immediately to prevent further harm to the client. Maintaining IV access and obtaining vital signs can be important steps but should come after stopping the transfusion to ensure the client's safety. Contacting the provider is necessary but not the first action to take in this situation. Therefore, the nurse should prioritize stopping the transfusion to address the potential adverse reaction.
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