ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A
1. A client with lactose intolerance needs to increase calcium intake. Which food should the nurse recommend?
- A. Spinach
- B. Peanut butter
- C. Ground beef
- D. Carrots
Correct answer: A
Rationale: Spinach is a suitable choice to recommend for increasing calcium intake to a client with lactose intolerance. Spinach is a good non-dairy source of calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium. Peanut butter is high in protein and fats, ground beef is a source of protein and iron, and carrots are rich in vitamin A and fiber, but none of these choices provide a substantial amount of calcium.
2. A client who gave birth 12 hours ago is experiencing excessive vaginal bleeding. Which of the following findings indicates the client is experiencing decreased cardiac output?
- A. Bradycardia
- B. Flushed face
- C. Hypotension
- D. Polyuria
Correct answer: C
Rationale: Hypotension is a key indicator of decreased cardiac output, especially in the context of postpartum hemorrhage, which can lead to significant fluid volume loss and compromise perfusion. In this scenario, the excessive vaginal bleeding could lead to hypovolemia, resulting in decreased cardiac output and subsequent hypotension. Bradycardia (choice A) is not typically associated with decreased cardiac output in this scenario, as the body often compensates for decreased cardiac output by increasing heart rate. A flushed face (choice B) may indicate vasodilation but is not a direct indicator of decreased cardiac output. Polyuria (choice D) is excessive urination and is not a specific indicator of decreased cardiac output in this context.
3. A nurse is planning discharge teaching for cord care for the parent of a newborn. Which instructions would you include in the teaching?
- A. Contact provider if the cord turns black
- B. Clean the base of the cord with hydrogen peroxide daily
- C. Keep the cord dry until it falls off
- D. The cord stump will fall off in ten days
Correct answer: C
Rationale: The correct instruction to include in the teaching for cord care is to keep the cord dry until it falls off naturally. This helps prevent infection, as the cord typically falls off in 10-14 days, not within five days. Instructing the parent to contact the provider if the cord turns black (Choice A) is important to monitor for signs of infection. Cleaning the base of the cord with hydrogen peroxide daily (Choice B) is not recommended as it can delay healing. Stating that the cord stump will fall off in ten days (Choice D) provides a more accurate timeframe compared to the initial estimation of five days.
4. A healthcare professional is preparing to administer a flu vaccine. Which of the following should the healthcare professional verify?
- A. Client's age
- B. Client's allergy to eggs
- C. Client's vaccination history
- D. Client's weight
Correct answer: C
Rationale: The healthcare professional should verify the client's vaccination history to ensure they are due for the flu vaccine. Verifying the client's age (choice A) is important for other vaccines but not specifically for the flu vaccine. While allergy to eggs (choice B) is relevant as the flu vaccine is traditionally produced in eggs, it is not the top priority for verification. The client's weight (choice D) is not directly related to the administration of the flu vaccine.
5. A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?
- A. Place the client on cardiac monitoring
- B. Monitor the client's oxygen saturation level
- C. Provide standby assistance when getting out of bed
- D. Encourage foods high in potassium
Correct answer: C
Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.
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