ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B Questions
Question 1 of 5
A healthcare professional is assessing a client with deep vein thrombosis (DVT). Which of the following interventions should the healthcare professional include in the plan of care?
Correct Answer: C
Rationale: Elevating the affected leg is a crucial intervention in the care of a client with deep vein thrombosis (DVT). This position helps reduce swelling and promotes venous return, which can alleviate symptoms associated with DVT. Applying ice packs (Choice A) may worsen the condition by causing vasoconstriction. Encouraging ambulation (Choice B) can dislodge the clot and lead to fatal complications. Massaging the affected area (Choice D) can also dislodge the clot and is contraindicated in DVT.
Question 2 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 3 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 4 of 5
A client at 38 weeks gestation with a history of herpes simplex virus 2 is being admitted. Which of the following questions is most appropriate to ask the client?
Correct Answer: B
Rationale: The most appropriate question to ask a client with a history of herpes simplex virus 2 at 38 weeks gestation is whether they have any active lesions. Active herpes lesions during labor can necessitate a cesarean delivery to prevent neonatal transmission. Asking about ruptured membranes (choice A), beta strep status (choice C), or contraction timing (choice D) is important but not the priority when managing a client with a history of herpes simplex virus 2 due to the high risk of neonatal transmission.
Question 5 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.