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 nurse is teaching a group of clients about stress management. Which of the following activities should the nurse recommend to reduce stress?
Correct Answer: B
Rationale: Deep breathing exercises are effective in reducing stress by promoting relaxation and lowering heart rate, making them a recommended technique. Watching television may not actively reduce stress but can serve as a distraction. Drinking coffee, which contains caffeine, may increase anxiety levels. Avoiding exercise can lead to pent-up stress and tension rather than reducing it.
Question 5 of 5
A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?
Correct Answer: A
Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.
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