ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A nurse is providing teaching to a client with a new diagnosis of diabetes mellitus. Which instruction should the nurse give to the client to monitor for hypoglycemia?
- A. Monitor for polyuria
- B. Monitor for diaphoresis
- C. Monitor for abdominal pain
- D. Monitor for thirst
Correct answer: B
Rationale: The correct answer is B: 'Monitor for diaphoresis.' Diaphoresis, which refers to excessive sweating, is a common symptom of hypoglycemia. It indicates a low blood sugar level and should prompt immediate treatment. Polyuria (excessive urination), abdominal pain, and thirst are not typically associated with hypoglycemia. Polyuria is more commonly linked to hyperglycemia, while abdominal pain and thirst are not specific symptoms of hypoglycemia.
2. A nurse is caring for a client who has been prescribed methadone. Which of the following client statements indicates a need for further teaching?
- A. I understand methadone slows my breathing.
- B. I understand methadone may cause me to have trouble sleeping.
- C. I will avoid alcohol while I’m taking this medication.
- D. I’ll change positions slowly, especially when standing.
Correct answer: B
Rationale: The correct answer is B because methadone typically causes sedation and respiratory depression, not trouble sleeping. The statement about trouble sleeping indicates a need for further teaching. Choices A, C, and D are incorrect because understanding that methadone slows breathing, avoiding alcohol while taking the medication, and changing positions slowly to prevent dizziness are all appropriate client statements when prescribed methadone.
3. A nurse is caring for a group of clients in a long-term care facility. Which of the following situations should the nurse recognize as a safety hazard?
- A. A client’s wrist restraints tied to the bed rails
- B. A client’s bedside table placed across the foot of the bed
- C. A meal tray left at the bedside from breakfast
- D. A call light extension cord pinned to the bedspread
Correct answer: A
Rationale: The correct answer is A. Tying wrist restraints to the bed rails is a safety hazard because if the bed rails are lowered, the restraints can tighten and cause injury or asphyxiation. Choice B, placing a bedside table across the foot of the bed, may not be ideal for convenience but does not pose a direct safety hazard. Choice C, leaving a meal tray at the bedside from breakfast, is more of an infection control issue than an immediate safety hazard. Choice D, having a call light extension cord pinned to the bedspread, is also not a direct safety hazard unless it poses a risk of entanglement or tripping, which is not indicated in the scenario.
4. A client has been prescribed albuterol. Which of the following is a priority adverse effect the nurse should monitor?
- A. Tachycardia
- B. Bradycardia
- C. Dizziness
- D. Hypertension
Correct answer: A
Rationale: Corrected Rationale: Albuterol, a beta-2 adrenergic agonist, can lead to tachycardia due to its stimulant effect on beta-2 receptors in the heart. Monitoring for tachycardia is crucial as it can be a sign of excessive sympathetic stimulation and may lead to severe complications. Bradycardia, dizziness, and hypertension are less likely adverse effects of albuterol, making them lower priority for monitoring in this context.
5. A nurse is sitting with the partner of a client who recently died. Which of the following actions should the nurse take to facilitate mourning?
- A. Encourage the partner to ask for help when needed
- B. Suggest the partner avoid discussing their feelings
- C. Recommend immediate return to daily activities
- D. Advise the partner to remain strong
Correct answer: A
Rationale: The correct action for the nurse to take to facilitate mourning is to encourage the partner to ask for help when needed. Grieving is a challenging process, and offering support and encouragement to seek help can be beneficial. Choice B is incorrect because avoiding discussing feelings can hinder the grieving process by suppressing emotions. Choice C is also incorrect as an immediate return to daily activities may not allow the partner to properly process their grief. Choice D is not the best approach as advising the partner to 'remain strong' may discourage the expression of emotions and seeking support, which are essential in the mourning process.
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