ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is providing teaching for a child who is prescribed ferrous sulfate. Which of the following instructions should the nurse include?
- A. Take the medication with milk
- B. Take with a glass of orange juice
- C. Take at bedtime
- D. Take with meals
Correct answer: B
Rationale: The correct answer is B: 'Take with a glass of orange juice.' Ferrous sulfate should be taken with orange juice (vitamin C) to enhance the absorption of iron. Taking it with milk (choice A) is not recommended as calcium can interfere with iron absorption. Taking it at bedtime (choice C) or with meals (choice D) may lead to decreased absorption due to interactions with other food or medications.
2. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate. Which of the following is an indication of magnesium toxicity?
- A. Blood glucose of 160 mg/dL
- B. Urine output of 20 mL/hour
- C. Systolic BP of 140 mm Hg
- D. Respiratory rate of 20/min
Correct answer: B
Rationale: The correct answer is B: Urine output of 20 mL/hour. Urine output below 30 mL/hour is a sign of magnesium toxicity due to the risk of accumulation in the body. Choices A, C, and D are not indicative of magnesium toxicity. Elevated blood glucose, systolic blood pressure, and normal respiratory rate are not specific signs of magnesium toxicity.
3. A nurse is reviewing the guidelines for reporting nationally notifiable infectious diseases. What disease should the nurse report to the CDC?
- A. Measles
- B. Hepatitis A
- C. Lyme disease
- D. Zika
Correct answer: C
Rationale: The correct answer is Lyme disease. Lyme disease must be reported to the CDC as it is a nationally notifiable infectious disease. It is spread by ticks and can lead to significant health issues if not monitored. Measles, Hepatitis A, and Zika are also important infectious diseases, but in this case, Lyme disease is the appropriate choice based on the information provided.
4. A nurse is teaching a newly licensed nurse about contraindications to ceftriaxone. The nurse should include a severe allergy to which of the following medications as a contraindication to ceftriaxone?
- A. Gentamicin
- B. Clindamycin
- C. Piperacillin
- D. Sulfamethoxazole-trimethoprim
Correct answer: C
Rationale: Ceftriaxone is a cephalosporin, and individuals with a penicillin allergy (such as Piperacillin) may have cross-sensitivity, making it contraindicated. Gentamicin (Choice A) belongs to the aminoglycoside class, not related to cephalosporins. Clindamycin (Choice B) is a lincosamide antibiotic and is not typically associated with cross-allergies to cephalosporins. Sulfamethoxazole-trimethoprim (Choice D) is a sulfonamide antibiotic, also not directly related to ceftriaxone.
5. A nurse should teach which of the following clients requiring crutches about how to use a three-point gait?
- A. A client who is able to bear full weight on both lower extremities.
- B. A client who has bilateral leg braces due to paralysis of the lower extremities.
- C. A client who has a right femur fracture with no weight bearing on the affected leg.
- D. A client who has bilateral knee replacements with partial weight bearing on both legs.
Correct answer: C
Rationale: The correct answer is C because a three-point gait is used when the client can bear full weight on one foot and uses crutches and the uninvolved leg to ambulate. Choices A, B, and D are incorrect because they do not meet the criteria for using a three-point gait. Choice A states that the client can bear full weight on both lower extremities, which does not require a three-point gait. Choice B mentions bilateral leg braces due to paralysis, which would not involve using a three-point gait. Choice D describes a client with bilateral knee replacements with partial weight bearing, which also does not align with the use of a three-point gait.
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