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 nurse is preparing to administer IV furosemide. Which of the following should the nurse monitor for during the infusion?
- A. Increased urinary output
- B. Ototoxicity
- C. Hypokalemia
- D. Hypoglycemia
Correct answer: C
Rationale: The correct answer is C: Hypokalemia. Furosemide is a loop diuretic that works by increasing the excretion of water and electrolytes, particularly potassium. Therefore, the nurse should monitor for hypokalemia, as low potassium levels can lead to various complications such as cardiac dysrhythmias. Choice A, increased urinary output, is an expected effect of furosemide due to its diuretic action but is not a side effect needing monitoring. Ototoxicity (Choice B) is a potential adverse effect of other medications like aminoglycoside antibiotics, not furosemide. Hypoglycemia (Choice D) is not a common side effect associated with furosemide administration.
3. A nurse is performing a focused assessment on a client who has a history of COPD and is experiencing dyspnea. Which of the findings should the nurse expect?
- A. Flaring of the nostrils
- B. Normal respiratory rate
- C. Clear lung sounds
- D. Decreased work of breathing
Correct answer: A
Rationale: Flaring of the nostrils indicates increased respiratory effort, common in clients with dyspnea due to COPD. In COPD, the airways are narrowed, causing difficulty in breathing, leading to increased work of breathing. Normal respiratory rate and clear lung sounds are less likely findings in a client with COPD experiencing dyspnea. Decreased work of breathing is not expected in this situation as COPD typically results in increased work of breathing.
4. A healthcare provider is assessing a client who has a heart rate of 40/min. The client is diaphoretic and has chest pain. Which of the following medications should the healthcare provider plan to administer?
- A. Lidocaine
- B. Adenosine
- C. Atropine
- D. Verapamil
Correct answer: C
Rationale: The client presents with bradycardia, diaphoresis, and chest pain, indicating reduced cardiac output. Atropine is the appropriate choice as it increases heart rate by blocking the parasympathetic nervous system. Lidocaine is used for ventricular arrhythmias, Adenosine for supraventricular tachycardia, and Verapamil for controlling heart rate in atrial fibrillation or atrial flutter. These medications are not suitable for the client's current presentation.
5. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?
- A. Urinary output of 40 mL/hr
- B. Respiratory rate of 10 breaths per minute
- C. Absent deep tendon reflexes
- D. Blood pressure of 150/90 mm Hg
Correct answer: B
Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention. Urinary output of 40 mL/hr (Choice A) is within the normal range for a client receiving magnesium sulfate. Absent deep tendon reflexes (Choice C) are an expected finding due to the medication's effect on neuromuscular excitability. A blood pressure of 150/90 mm Hg (Choice D) is slightly elevated but not a priority concern compared to severe respiratory depression.
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