ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A client with ulcerative colitis has been prescribed sulfasalazine. The nurse should instruct the client to monitor for which of the following adverse effects of this medication?
- A. Jaundice
- B. Constipation
- C. Oral candidiasis
- D. Sedation
Correct answer: A
Rationale: The correct answer is A: Jaundice. Sulfasalazine can cause liver damage as a possible adverse effect, which can manifest as jaundice. Monitoring for jaundice is crucial to detect liver-related adverse effects early. Choices B, C, and D are incorrect. Constipation, oral candidiasis, and sedation are not typically associated with sulfasalazine use. Therefore, the nurse should focus on educating the client specifically about monitoring for jaundice.
2. A nurse is caring for a client who has a prescription for clopidogrel. The nurse should monitor the client for which of the following adverse effects?
- A. Insomnia
- B. Hypotension
- C. Bleeding
- D. Constipation
Correct answer: C
Rationale: The correct answer is C: Bleeding. Clopidogrel is an antiplatelet medication that works by preventing platelets from sticking together and forming clots. Therefore, one of the main adverse effects of clopidogrel is an increased risk of bleeding. Insomnia (Choice A), hypotension (Choice B), and constipation (Choice D) are not commonly associated with clopidogrel use. Monitoring for signs of bleeding, such as easy bruising, petechiae, or prolonged bleeding from minor cuts, is crucial when a client is taking clopidogrel.
3. A nurse is administering subcutaneous heparin to a client who is at risk for deep vein thrombosis. Which of the following actions should the nurse take?
- A. Administer the medication into the client's abdomen.
- B. Inject the medication into a muscle.
- C. Massage the site after administering the medication.
- D. Use a 22-gauge needle to administer the medication.
Correct answer: A
Rationale: Heparin is best absorbed and less likely to cause hematomas when administered into subcutaneous tissue, specifically the abdomen, which is a common site for subcutaneous injections. Injecting heparin into a muscle (Choice B) is incorrect as it should be administered subcutaneously. Massaging the site after administering the medication (Choice C) is contraindicated as it can cause tissue damage or bruising. Using a 22-gauge needle (Choice D) is not recommended for subcutaneous injections of heparin; a smaller needle size such as 25-26 gauge is preferred for subcutaneous administration.
4. A nurse is caring for a client who has a prescription for chlorothiazide to treat hypertension. The nurse should plan to monitor the client for which of the following adverse effects?
- A. Thrombophlebitis
- B. Hyperactive reflexes
- C. Muscle weakness
- D. Hypoglycemia
Correct answer: C
Rationale: The correct answer is C: Muscle weakness. Chlorothiazide, a thiazide diuretic, can lead to hypokalemia, which can cause muscle weakness. Thrombophlebitis (choice A) is not typically associated with chlorothiazide use. Hyperactive reflexes (choice B) and hypoglycemia (choice D) are also not commonly linked to this medication. Therefore, monitoring for muscle weakness is crucial when a client is prescribed chlorothiazide.
5. A nurse is providing teaching to a newly licensed nurse about metoclopramide. The nurse should include in the teaching that which of the following conditions is a contraindication to this medication?
- A. Hyperthyroidism
- B. Intestinal obstruction
- C. Glaucoma
- D. Low blood pressure
Correct answer: B
Rationale: The correct answer is B: Intestinal obstruction. Metoclopramide is contraindicated in clients with intestinal obstruction due to its prokinetic effects, which could exacerbate the condition. Choices A, C, and D are incorrect because metoclopramide is not contraindicated in hyperthyroidism, glaucoma, or low blood pressure. Hyperthyroidism, glaucoma, and low blood pressure are not specific contraindications for metoclopramide use, and this medication is commonly prescribed for conditions like gastroesophageal reflux disease and diabetic gastroparesis.
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