ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B Questions
Question 1 of 5
A nurse is planning care for a client who has a chest tube. Which of the following actions should the nurse take to ensure proper functioning of the chest tube?
Correct Answer: B
Rationale:
To ensure proper functioning of a chest tube, the nurse should keep the drainage system below chest level. This position allows for proper drainage by gravity and prevents backflow into the pleural space. Clamping the chest tube intermittently can lead to a buildup of pressure and should be avoided. Emptying the drainage chamber every 4 hours is important but not directly related to maintaining the chest tube's function. Applying sterile gauze around the insertion site daily is essential for infection prevention but does not specifically ensure the proper functioning of the chest tube.
Question 2 of 5
A nurse is caring for a client with a new prescription for enoxaparin to prevent DVT. Which of the following is an appropriate action by the nurse?
Correct Answer: B
Rationale: The correct answer is to inject enoxaparin in the lateral abdominal wall. This site is typically recommended for subcutaneous injections of this medication. Expelling air bubbles from prefilled syringes is not necessary and may result in medication loss. Massaging the injection site is contraindicated as it can cause bruising or hematoma formation. Administering NSAIDs for injection site discomfort is unnecessary and not a standard practice.
Question 3 of 5
A nurse is assessing a client who has a history of atrial fibrillation and is receiving warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the warfarin?
Correct Answer: B
Rationale: The correct answer is B: International normalized ratio (INR). The INR is used to monitor the effectiveness of warfarin therapy. A higher INR indicates a longer time it takes for the blood to clot, which is desirable in patients receiving warfarin to prevent blood clots. Platelet count (
Choice
A) assesses the number of platelets in the blood and is not directly related to warfarin therapy. Bleeding time (
Choice
C) evaluates the time it takes for a person to stop bleeding after a standardized wound, but it is not specific to monitoring warfarin effectiveness. Partial thromboplastin time (PTT) (
Choice
D) is more commonly used to monitor heparin therapy, not warfarin.
Question 4 of 5
A client with preeclampsia is receiving magnesium sulfate. Which finding indicates magnesium toxicity?
Correct Answer: A
Rationale: The correct answer is A: Decreased deep tendon reflexes. In a client receiving magnesium sulfate for preeclampsia, decreased deep tendon reflexes indicate magnesium toxicity. Magnesium toxicity can lead to respiratory depression and other serious complications, requiring immediate intervention.
Choices B, C, and D are incorrect because increased blood pressure, tachypnea, and hyperreflexia are not typical findings associated with magnesium toxicity.
Question 5 of 5
A nurse is caring for a client with a recent diagnosis of myasthenia gravis. Which of the following medications should the nurse expect to administer?
Correct Answer: B
Rationale: Pyridostigmine is the drug of choice for treating myasthenia gravis because it enhances communication between nerves and muscles by inhibiting acetylcholinesterase. Methotrexate (choice
A) is not indicated for myasthenia gravis but is used in conditions like rheumatoid arthritis. Baclofen (choice
C) is a muscle relaxant used for conditions like spasticity. Atropine (choice
D) is not typically used in myasthenia gravis as it can worsen muscle weakness.