ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment 2020 A
1. A nurse is preparing to administer heparin 8,000 units subcutaneously every eight hours. The amount available is heparin injection 10,000 units/mL. How many milliliters should the nurse administer per dose? (Round the answer to the nearest tenth)
- A. 0.8 mL
- B. 0.9 mL
- C. 10.0 mL
- D. 98.0 mL
Correct answer: A
Rationale: To determine the volume of heparin to administer per dose, divide the prescribed dose (8,000 units) by the concentration of heparin available (10,000 units/mL). 8000 units / 10000 units/mL = 0.8 mL. Therefore, the nurse should administer 0.8 mL per dose. Choice B, 0.9 mL, is incorrect as the correct calculation results in 0.8 mL. Choices C and D are significantly higher and incorrect, indicating an inaccurate calculation.
2. A nurse is caring for a client who has been taking isoniazid and rifampin for 3 weeks for the treatment of active pulmonary tuberculosis (TB). The client reports his urine is an orange color. Which of the following statements should the nurse make?
- A. Stop taking the isoniazid for 3 days and the discoloration should go away.
- B. Rifampin can turn body fluids orange.
- C. I'll make an appointment for you to see the provider this afternoon.
- D. Isoniazid can cause bladder irritation.
Correct answer: B
Rationale: The correct answer is B: 'Rifampin can turn body fluids orange.' Rifampin is known to cause orange discoloration of body fluids, including urine. This side effect is harmless and does not indicate a need to stop the medication. Choice A is incorrect because stopping isoniazid will not resolve the orange urine discoloration caused by rifampin. Choice C is unnecessary at this point since the orange urine is a known side effect of rifampin and does not require an urgent provider visit. Choice D is incorrect because bladder irritation is not typically associated with isoniazid.
3. A nurse is caring for an older adult client who has a prescription for zolpidem at bedtime to promote sleep. The nurse should plan to monitor the client for which of the following adverse effects?
- A. Ecchymosis
- B. Decreased urine output
- C. Increased blood pressure
- D. Dizziness
Correct answer: D
Rationale: The correct answer is D: Dizziness. Zolpidem is known to cause dizziness, especially in older adults. This adverse effect can increase the risk of falls and injuries in the elderly population. Monitoring for dizziness is crucial to ensure patient safety. Choice A, Ecchymosis, is the development of bruising and is not a common adverse effect of zolpidem. Choices B and C, Decreased urine output and Increased blood pressure, are not typically associated with zolpidem use. Therefore, they are incorrect choices in this scenario.
4. A nurse is providing discharge teaching to a client who has heart failure and a new prescription for digoxin 0.215 mg PO daily and furosemide 20 mg PO daily. Which of the following statements by the client indicates an understanding of the teaching?
- A. I know that blurred vision is something I will expect to happen while taking digoxin.
- B. I will measure my urine output each day and document it in my diary.
- C. I will skip a dose of my digoxin if my resting heart rate is below 72 beats per minute.
- D. I will eat fruits and vegetables that have high potassium content every day.
Correct answer: D
Rationale: Clients taking digoxin and furosemide are at risk for hypokalemia. Eating potassium-rich foods can help maintain normal potassium levels.
5. 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.
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