ATI LPN
PN ATI Capstone Proctored Comprehensive Assessment Form B Questions
Question 1 of 5
A nurse is planning care to prevent complications in a client with immobility. Which of the following interventions should the nurse include?
Correct Answer: B
Rationale: The correct answer is B because removing anti-embolism stockings for short periods prevents skin breakdown while ensuring that the stockings remain effective in promoting circulation. Choice A is incorrect because massaging lower extremities daily does not prevent DVT; instead, it may dislodge a clot. Choice C is incorrect as limiting intake of foods high in calcium does not prevent renal calculi; rather, it may help reduce the risk of kidney stones. Choice D is incorrect because encouraging the client to lie supine does not prevent constipation; instead, encouraging mobility and adequate fluid intake can help prevent constipation in immobile clients.
Question 2 of 5
A healthcare provider is assessing a client who is receiving heparin therapy for deep vein thrombosis (DVT). Which of the following laboratory values should the provider monitor to evaluate the therapeutic effect of the heparin?
Correct Answer: B
Rationale: The Partial Thromboplastin Time (PTT) is the correct laboratory value to monitor heparin therapy. PTT measures the time it takes for blood to clot and is specifically used to evaluate the effectiveness of anticoagulation therapy such as heparin. Monitoring the PTT helps ensure that the heparin dose is within the therapeutic range. Platelet count, Prothrombin time (PT), and Bleeding time are not specific laboratory values for monitoring the therapeutic effect of heparin therapy. Platelet count is more indicative of platelet function, PT is used to monitor warfarin therapy, and Bleeding time assesses platelet function rather than the effect of heparin therapy.
Question 3 of 5
A nurse is caring for a client who is 2 hours postpartum following a vaginal birth. The client reports heavy bleeding and passing large clots. What is the priority action for the nurse to take?
Correct Answer: B
Rationale: Performing fundal massage is the priority action to take in this situation. Fundal massage helps stimulate uterine contractions, which can reduce postpartum bleeding. Uterine atony, the most common cause of early postpartum hemorrhage, can be addressed effectively through fundal massage. Administering oxytocin IV, although important, should come after initiating fundal massage. Checking vital signs is also crucial but not the immediate priority. Encouraging the client to void does not directly address the heavy bleeding and passing of large clots; hence, it is not the priority action.
Question 4 of 5
A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate. The nurse should monitor the client for which of the following findings as an indication of magnesium toxicity?
Correct Answer: A
Rationale: The correct answer is A: Decreased deep tendon reflexes. Magnesium sulfate toxicity can lead to diminished deep tendon reflexes, respiratory depression, and decreased urine output. Diminished deep tendon reflexes are an early sign of magnesium toxicity and indicate the need to discontinue the infusion. Elevated blood pressure (choice B) is not typically associated with magnesium toxicity. Increased urinary output (choice C) is also not a common finding in magnesium toxicity. Hyperreflexia (choice D) is not consistent with the expected findings of magnesium toxicity, which typically causes decreased reflexes.
Question 5 of 5
A client with a new diagnosis of heart failure is prescribed furosemide. Which of the following instructions should the nurse include?
Correct Answer: B
Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide, a loop diuretic, can lead to potassium loss, which may cause hypokalemia. Increasing potassium intake can help prevent this electrolyte imbalance. Choice A is incorrect because furosemide is usually taken in the morning to prevent sleep disturbances due to increased urination. Choice C is incorrect because a decrease in urine output could indicate a problem and should be reported immediately. Choice D is incorrect because furosemide is used to reduce swelling in the body, including the lower extremities, so expecting swelling is not appropriate.