ATI LPN
PN ATI Capstone Maternal Newborn
1. A nurse providing dietary teaching for a client who is at 29 weeks of gestation and has phenylketonuria. Which of the following suggested foods should the nurse include in the teaching?
- A. A peanut butter sandwich on wheat bread
- B. A sliced apple and red grapes
- C. A chocolate chip cookie with a glass of skim milk
- D. A scrambled egg with cheddar cheese
Correct answer: B
Rationale: The correct answer is B. Clients with phenylketonuria (PKU) must adhere to a strict low-phenylalanine diet to prevent neurological damage. Foods high in phenylalanine such as peanut butter, wheat bread, chocolate chip cookies, milk, scrambled eggs, and cheddar cheese should be avoided. Sliced apples and red grapes are low in phenylalanine, making them safe choices for individuals with PKU. Choice A (peanut butter sandwich on wheat bread), Choice C (chocolate chip cookie with a glass of skim milk), and Choice D (scrambled egg with cheddar cheese) are all high in phenylalanine and should be avoided by individuals with PKU.
2. During a breast examination on a 24-year-old client, the nurse notes the following findings. Which finding is of most concern and should be reported to the provider?
- A. An irregularly shaped, nontender lump palpable in the right breast
- B. Tenderness present during menstruation
- C. Bilateral, symmetrical lumps that move with palpation
- D. The client reports breast tenderness before menstruation
Correct answer: A
Rationale: An irregularly shaped, nontender lump is a concerning finding as it may indicate breast cancer. The nurse should report this finding to the provider for further investigation. Choices B, C, and D are less concerning findings. Tenderness during menstruation is a common finding due to hormonal changes. Bilateral, symmetrical lumps that move with palpation are often benign findings like fibrocystic changes. Breast tenderness before menstruation is also a common occurrence related to hormonal fluctuations.
3. Which of the following are contraindications to salicylic acid therapy?
- A. Third trimester of pregnancy
- B. Thrombocytopenia
- C. Coronary artery disease
- D. Adolescents with chickenpox
Correct answer: A
Rationale: The correct answer is A: Third trimester of pregnancy. Salicylic acid is contraindicated during the third trimester of pregnancy due to the risk of complications for both the mother and the fetus. Thrombocytopenia (choice B) is not a contraindication to salicylic acid therapy. Coronary artery disease (choice C) is not a specific contraindication to salicylic acid therapy. However, caution should be exercised in patients with coronary artery disease due to the antiplatelet effects of salicylic acid. Adolescents with chickenpox (choice D) should not be given salicylic acid due to the risk of Reye Syndrome, a rare but serious illness.
4. A nurse is caring for a client with a new prescription for furosemide. Which of the following should the nurse monitor?
- A. Serum potassium levels
- B. Liver function
- C. Blood glucose levels
- D. Calcium levels
Correct answer: A
Rationale: Corrected Rationale: When a client is prescribed furosemide, the nurse should monitor serum potassium levels. Furosemide is a loop diuretic that can lead to potassium loss, potentially causing hypokalemia. Monitoring serum potassium levels is crucial to prevent complications such as cardiac dysrhythmias. Choices B, C, and D are incorrect because furosemide primarily affects potassium excretion rather than liver function, blood glucose levels, or calcium levels.
5. A client is being educated by a nurse on nutritional intake. Which of the following should the nurse include in the teaching?
- A. Carbohydrates should be at least 45% of your caloric intake
- B. Protein should be at least 55% of your caloric intake
- C. Carbohydrates should be at least 30% of your caloric intake
- D. Protein should be at least 60% of your caloric intake
Correct answer: A
Rationale: Carbohydrates should make up 45-65% of daily caloric intake as they are the body’s main source of energy. This aligns with general dietary recommendations. Choice B is incorrect as protein should typically make up about 10-35% of daily caloric intake, not 55%. Choice C is also incorrect, as carbohydrates should ideally be between 45-65%, not 30%. Choice D is incorrect because protein should generally account for around 10-35% of total caloric intake, not 60%.
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