ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B Questions
Question 1 of 5
A client is receiving oxytocin to augment labor. The contractions are occurring every 45 seconds, and the fetal heart rate is 170-180 beats/min. What action should the nurse take?
Correct Answer: C
Rationale: When contractions occur every 45 seconds with a high fetal heart rate, it indicates uterine hyperstimulation and fetal distress. In this situation, the oxytocin infusion should be discontinued immediately to prevent further complications. Increasing or maintaining the infusion would worsen the hyperstimulation and distress. Decreasing the infusion may not be sufficient to address the current situation and could still lead to complications.
Question 2 of 5
A nurse is providing teaching for a child who is prescribed ferrous sulfate. Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: The correct answer is B: 'Take with a glass of orange juice.' Ferrous sulfate should be taken with orange juice (vitamin C) to enhance the absorption of iron. Taking it with milk (choice A) is not recommended as calcium can interfere with iron absorption. Taking it at bedtime (choice C) or with meals (choice D) may lead to decreased absorption due to interactions with other food or medications.
Question 3 of 5
A nurse in the emergency department is prioritizing care for four clients. Which of the following clients should the nurse see first?
Correct Answer: D
Rationale: The client with slurred speech, disorientation, and a headache may be experiencing a stroke, a life-threatening condition that requires immediate attention. Identifying and managing a stroke promptly can reduce the risk of long-term disability or complications. The other options, although important, do not present immediate life-threatening conditions that require urgent intervention. A dislocated shoulder, severe joint pain in sickle cell disease, confusion with fever and foul-smelling urine, while concerning, can be addressed after attending to the client with potential stroke symptoms.
Question 4 of 5
A nurse is completing a dietary assessment for a client who observes kosher dietary practices. Which of the following behaviors should the nurse expect?
Correct Answer: C
Rationale: The correct answer is C: 'Meat and dairy products are eaten separately.' In kosher dietary practices, it is essential to keep meat and dairy products separate. Mixing meat and dairy is prohibited, and there are specific guidelines for the preparation and consumption of each. Choices A, B, and D are incorrect. Choice A is wrong because leavened bread is not eaten during Passover in kosher practices. Choice B is incorrect as shellfish is not consumed in a kosher diet. Choice D is also inaccurate as fasting from meat does not occur during Hanukkah in kosher dietary practices.
Question 5 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.