ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B Questions
Question 1 of 5
A nurse is caring for a client who has been receiving oxytocin IV for labor augmentation. The client's contractions are occurring every 2 minutes and lasting 90 seconds. What action should the nurse take?
Correct Answer: B
Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. The client is experiencing uterine hyperstimulation, as evidenced by contractions occurring every 2 minutes and lasting 90 seconds. Discontinuing the oxytocin is crucial to prevent fetal distress and uterine rupture. Increasing the IV fluid rate would not address the uterine hyperstimulation caused by oxytocin. Applying an internal fetal monitor is not the priority at this moment; first, the oxytocin infusion needs to be stopped to manage the uterine hyperstimulation effectively.
Question 2 of 5
A client is experiencing suicidal thoughts and states, 'Why not end my misery?' What is the best response by the nurse?
Correct Answer: B
Rationale: The correct answer is B: 'Do you have a plan to end your life?' When a client expresses suicidal thoughts, it is crucial to assess the immediate risk. Inquiring about a specific plan can help determine the seriousness of the situation. Choice A is less direct and may not provide a clear indication of the immediate risk. Choice C focuses on the interpretation of 'misery' rather than assessing the risk of suicide. Choice D offers support but does not address the critical assessment of the client's immediate safety.
Question 3 of 5
A nurse is caring for a client with a prescription for ferrous sulfate. What instruction should the nurse provide?
Correct Answer: B
Rationale: The correct instruction for a client prescribed ferrous sulfate is to take it with fluids other than coffee or tea. Coffee and tea can hinder iron absorption, so it's important to take the medication with other types of fluids. Choice A is incorrect because strawberries and citrus fruits are sources of vitamin C, which actually enhance iron absorption. Choice C is incorrect because ferrous sulfate is usually recommended to be taken on an empty stomach for better absorption. Choice D is incorrect as doubling the dose of ferrous sulfate can lead to an overdose and severe side effects.
Question 4 of 5
A client with preeclampsia is receiving magnesium sulfate. Which finding indicates magnesium toxicity?
Correct Answer: A
Rationale: The correct answer is A: Decreased deep tendon reflexes. In a client receiving magnesium sulfate for preeclampsia, decreased deep tendon reflexes indicate magnesium toxicity. Magnesium toxicity can lead to respiratory depression and other serious complications, requiring immediate intervention. Choices B, C, and D are incorrect because increased blood pressure, tachypnea, and hyperreflexia are not typical findings associated with magnesium toxicity.
Question 5 of 5
A nurse is preparing to administer a client's first dose of a new antibiotic. Which of the following is the priority nursing action?
Correct Answer: A
Rationale: Assessing allergies before administering a new medication is crucial as it helps prevent potentially life-threatening allergic reactions like anaphylaxis. While monitoring vital signs and informing the client of side effects are important nursing actions, assessing allergies takes precedence to ensure the client's safety. Informed consent is necessary for the treatment process, but assessing allergies is the priority before administering any new medication.
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