ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment A Questions
Question 1 of 5
A client just received the first dose of lisinopril. Which of the following is an appropriate nursing intervention?
Correct Answer: C
Rationale: The correct answer is to provide standby assistance when getting out of bed. Lisinopril can cause first-dose hypotension, leading to dizziness and increasing the risk of falls. Standby assistance helps ensure the client's safety when mobilizing. Placing the client on cardiac monitoring (choice A) is not necessary unless there are specific indications for cardiac monitoring. Monitoring oxygen saturation (choice B) is not directly related to the side effects of lisinopril. Encouraging foods high in potassium (choice D) is not the most immediate or appropriate intervention following the administration of lisinopril.
Question 2 of 5
A nurse is caring for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication for hemodialysis?
Correct Answer: A
Rationale: A glomerular filtration rate (GFR) of 14 mL/min indicates severely impaired kidney function, often necessitating hemodialysis to support renal function and manage fluid and electrolyte balance. A BUN level of 16 mg/dL falls within the normal range (7-20 mg/dL) and does not specifically indicate the need for hemodialysis. Serum magnesium at 1.8 mg/dL and serum phosphorus at 4.0 mg/dL are also within normal ranges and do not typically prompt the immediate need for hemodialysis in chronic kidney disease.
Question 3 of 5
A nurse is caring for an infant who has a prescription for continuous pulse oximetry. Which of the following is an appropriate action for the nurse to take?
Correct Answer: B
Rationale: The correct answer is to move the probe site every 3 hours. This action helps prevent skin breakdown and ensures more accurate monitoring of oxygen saturation. Placing the infant under a radiant warmer (choice A) is unnecessary and not related to pulse oximetry. Heating the skin before placing the probe (choice C) can lead to burns and is not recommended. Placing the sensor on the index finger (choice D) is not appropriate for continuous monitoring in infants.
Question 4 of 5
A nurse in a mental health facility receives a change-of-shift report on four clients. Which of the following clients should the nurse assess first?
Correct Answer: A
Rationale: A client in restraints due to aggressive behavior needs immediate assessment to ensure safety and well-being. The nurse should assess this client first to address any potential risks, such as circulation issues, skin integrity problems, and ongoing agitation. Choices B, C, and D do not present immediate safety concerns that require urgent assessment compared to a client restrained for aggressive behavior.
Question 5 of 5
A nurse working at the clinic is teaching a group of clients who are pregnant on the use of nonpharmacological pain management. Which of the following is an appropriate description of the use of hypnosis during labor?
Correct Answer: B
Rationale: The correct answer is B. Hypnosis during labor helps the client gain increased control over her perception of pain, allowing for better pain management during contractions. Choice A is incorrect because hypnosis and biofeedback are distinct techniques. Choice C is incorrect as therapeutic touch and hypnosis are different modalities. Choice D is incorrect as hypnosis does not simply provide instruction to minimize pain, but rather helps the individual control their perception of pain.