ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B Questions
Question 1 of 5
A client who is 38 weeks pregnant with herpes simplex virus is admitted to labor and delivery. What question should the nurse ask?
Correct Answer: A
Rationale: The correct question the nurse should ask the client who is 38 weeks pregnant with herpes simplex virus is 'Do you have any active lesions?' This is crucial because active herpes lesions may necessitate a cesarean delivery to prevent neonatal infection.
Choice B, 'Have your membranes ruptured?' is related to assessing for the rupture of membranes, not specific to the client's herpes infection.
Choice C, 'How far apart are your contractions?' is related to monitoring labor progress.
Choice D, 'Are you positive for beta strep?' is related to group B streptococcus screening, which is important but not the priority in this scenario.
Question 2 of 5
A nurse is caring for a client at 32 weeks gestation with a history of cardiac disease. Which position should the nurse recommend to promote optimal cardiac output?
Correct Answer: D
Rationale: The left lateral position is the correct choice to promote optimal cardiac output in a pregnant client at 32 weeks gestation with cardiac disease. This position improves venous return and decreases pressure on the vena cava, helping optimize cardiac output. Standing (choice
B) would not be recommended as it may decrease venous return. The supine position (choice
C) should be avoided in pregnant clients with cardiac disease as it can compress the vena cava, reducing cardiac output and potentially causing hypotension. The chest (choice
A) is not a valid position recommendation for optimizing cardiac output in this scenario.
Question 3 of 5
A nurse is caring for a client with deep vein thrombosis (DVT). Which of the following interventions should the nurse include in the plan of care?
Correct Answer: D
Rationale: The correct answer is to elevate the affected leg while in bed. Elevating the leg helps reduce swelling and promotes venous return, aiding in the management of DVT. Positioning the affected leg below the heart can worsen the condition by increasing the risk of clot dislodgment. Massaging the affected extremity can also dislodge the clot and should be avoided. Cold compresses are not recommended as they can cause vasoconstriction, potentially worsening the condition.
Question 4 of 5
A nurse is planning care to prevent complications in a client with immobility. Which of the following interventions should the nurse include?
Correct Answer: B
Rationale: The correct answer is B because removing anti-embolism stockings for short periods prevents skin breakdown while ensuring that the stockings remain effective in promoting circulation.
Choice A is incorrect because massaging lower extremities daily does not prevent DVT; instead, it may dislodge a clot.
Choice C is incorrect as limiting intake of foods high in calcium does not prevent renal calculi; rather, it may help reduce the risk of kidney stones.
Choice D is incorrect because encouraging the client to lie supine does not prevent constipation; instead, encouraging mobility and adequate fluid intake can help prevent constipation in immobile clients.
Question 5 of 5
A nurse receives a report on four clients. Which client should the nurse assess first?
Correct Answer: C
Rationale: The correct answer is C. Low back pain during a blood transfusion is a classic sign of a transfusion reaction, specifically a transfusion-associated circulatory overload (TACO) or hemolytic reaction, both of which require immediate attention to prevent serious complications. Assessing this client first is crucial to ensure prompt intervention.
Choices A, B, and D do not indicate immediate life-threatening complications and can be addressed after the client experiencing low back pain during a blood transfusion is stabilized.