ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form A Questions
Question 1 of 9
A client receiving oxytocin IV for labor augmentation is experiencing contractions every 45 seconds. What action should the nurse take?
Correct Answer: A
Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. Contractions occurring every 45 seconds indicate uterine hyperstimulation, which can pose risks to both the client and the fetus. By stopping the oxytocin infusion, the nurse can help prevent further complications. Choices B, C, and D are incorrect because increasing, decreasing, or maintaining the oxytocin infusion can exacerbate the uterine hyperstimulation and increase the risks associated with it.
Question 2 of 9
A nurse is assessing a client 1 hour after birth and notes a boggy uterus located 2 cm above the umbilicus. What should the nurse do first?
Correct Answer: C
Rationale: A boggy uterus located 2 cm above the umbilicus suggests uterine atony, which is a common cause of postpartum hemorrhage. The initial intervention in this situation is to massage the fundus. Fundal massage helps the uterus contract, promoting hemostasis and preventing excessive bleeding. Taking vital signs or assessing lochia are important actions but are secondary to addressing uterine atony. Administering oxytocin IV bolus is often done after fundal massage to further enhance uterine contractions.
Question 3 of 9
A client has a stool culture positive for C. difficile. What action should the nurse take?
Correct Answer: D
Rationale: When caring for a client with a C. difficile infection, it is essential to isolate them in a private room to prevent the spread of spores through contact with surfaces. Placing the client in a negative pressure room (Choice A) is not necessary for C. difficile. Using alcohol-based hand rub (Choice B) and wearing a face shield (Choice C) are important infection control measures but are not specific to the isolation requirements for C. difficile.
Question 4 of 9
A nurse is caring for a client with deep vein thrombosis (DVT). Which action should the nurse take?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 5 of 9
A client with lactose intolerance needs to increase calcium intake. Which food should the nurse recommend?
Correct Answer: A
Rationale: Spinach is a suitable choice to recommend for increasing calcium intake to a client with lactose intolerance. Spinach is a good non-dairy source of calcium. Peanut butter, ground beef, and carrots are not significant sources of calcium. Peanut butter is high in protein and fats, ground beef is a source of protein and iron, and carrots are rich in vitamin A and fiber, but none of these choices provide a substantial amount of calcium.
Question 6 of 9
A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which is a contraindication for this vaccine?
Correct Answer: A
Rationale: The correct answer is A: Recent blood transfusion. A recent blood transfusion can interfere with the effectiveness of the MMR vaccine, making it a contraindication. Choice B, allergy to penicillin, is not a contraindication for the MMR vaccine. Choice C, minor acute illness, is not a contraindication unless the child has a moderate to severe illness. Choice D, low-grade fever, is not a contraindication as long as the child does not have a moderate to severe febrile illness.
Question 7 of 9
A nurse is providing teaching to a client with a new diagnosis of diabetes mellitus. Which instruction should the nurse give to the client to monitor for hypoglycemia?
Correct Answer: B
Rationale: The correct answer is B: 'Monitor for diaphoresis.' Diaphoresis, which refers to excessive sweating, is a common symptom of hypoglycemia. It indicates a low blood sugar level and should prompt immediate treatment. Polyuria (excessive urination), abdominal pain, and thirst are not typically associated with hypoglycemia. Polyuria is more commonly linked to hyperglycemia, while abdominal pain and thirst are not specific symptoms of hypoglycemia.
Question 8 of 9
A client is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?
Correct Answer: B
Rationale: Diminished deep tendon reflexes are a sign of magnesium toxicity. Magnesium sulfate can depress the central nervous system, leading to decreased reflexes. Respiratory rate of 12/min, urine output 40 mL/hr, and systolic blood pressure of 140 mm Hg are not specific findings of magnesium toxicity. Respiratory depression, oliguria, and hypotension are more concerning signs that require immediate attention.
Question 9 of 9
A nurse is caring for four clients. Which client should the nurse assess first?
Correct Answer: C
Rationale: The correct answer is C. The client with hypothyroidism who is stuporous should be assessed first as this may indicate a critical condition, possibly related to severe hypothyroidism. Stupor is a state of near-unconsciousness or insensibility, suggesting a decline in neurological function that requires immediate evaluation. Choices A, B, and D do not present with immediate life-threatening conditions that require urgent assessment. While chemotherapy, post-appendectomy complications, and burn care are important, they do not pose the same level of immediate risk as a stuporous client.