ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B
1. A nurse is providing teaching for a client who has a new prescription for sertraline. Which of the following statements by the client indicates understanding?
- A. I will feel better immediately after starting this medication.
- B. I can expect to urinate frequently while taking this medication.
- C. I may experience difficulty sleeping while taking this medication.
- D. I should decrease my sodium intake while taking this medication.
Correct answer: C
Rationale: The correct answer is C: 'I may experience difficulty sleeping while taking this medication.' Sertraline can cause insomnia, especially when first starting the medication, so the client should be aware of this potential side effect. Choices A, B, and D are incorrect because feeling better immediately, increased urination, and decreasing sodium intake are not commonly associated side effects of sertraline.
2. A nurse is caring for a client who is receiving oxytocin to augment labor. The nurse notes recurrent variable decelerations of the FHR. Which of the following actions should the nurse take first?
- A. Prepare the equipment necessary to initiate an amnioinfusion
- B. Administer oxygen at 10 L/min via a non-rebreather face mask
- C. Discontinue the infusion of oxytocin
- D. Place the client in a left lateral position
Correct answer: C
Rationale: The correct first action for the nurse to take is to discontinue the infusion of oxytocin. Oxytocin can lead to uterine hyperstimulation and fetal distress, contributing to variable decelerations in fetal heart rate. By stopping the oxytocin infusion, the nurse can promptly assess and manage the fetal heart rate. Choice A, preparing for amnioinfusion, is not the priority when faced with recurrent variable decelerations. Choice B, administering oxygen, is important but addressing the oxytocin infusion issue takes precedence. Choice D, placing the client in a left lateral position, is beneficial for optimizing fetal oxygenation but discontinuing oxytocin is the initial step in managing variable decelerations.
3. A client has been prescribed phenytoin. Which of the following should the nurse monitor to prevent toxicity?
- A. Blood pressure
- B. Complete blood count
- C. Serum phenytoin levels
- D. Liver function tests
Correct answer: C
Rationale: Corrected Rationale: Serum phenytoin levels should be regularly monitored to prevent toxicity because the therapeutic range is narrow. Monitoring blood pressure (choice A), complete blood count (choice B), and liver function tests (choice D) are not directly related to preventing phenytoin toxicity.
4. A nurse is preparing to administer a dose of escitalopram. Which of the following should the nurse assess first?
- A. Mood changes
- B. Blood pressure
- C. Heart rate
- D. Liver function
Correct answer: A
Rationale: The correct answer is to assess for mood changes. When administering escitalopram, it is crucial to evaluate mood changes first because the medication may take some time to demonstrate its full effects on the patient's mood. Assessing blood pressure, heart rate, or liver function is not the priority when administering escitalopram, as these parameters are not directly impacted acutely by this medication.
5. A healthcare provider is caring for a client with severe preeclampsia. Which of the following medications should the healthcare provider anticipate administering?
- A. Magnesium sulfate
- B. Oxytocin
- C. Misoprostol
- D. Nifedipine
Correct answer: A
Rationale: Magnesium sulfate is the correct answer as it is administered to prevent seizures in clients with severe preeclampsia. It acts as a central nervous system depressant and is the first-line treatment for eclampsia prevention. Oxytocin (Choice B) is used to induce or augment labor, not indicated specifically for preeclampsia. Misoprostol (Choice C) is used for labor induction and postpartum hemorrhage, not typically indicated for preeclampsia. Nifedipine (Choice D) is a calcium channel blocker used for managing hypertension in pregnancy but is not the first-line treatment for preventing seizures in severe preeclampsia.
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