ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 3 : The Nursing Process Questions
Question 1 of 5
A client being cared for by the healthcare team has a large open abdominal wound after having a surgical procedure. The wound had to be reopened due to the development of infection and is left to heal with packing and dressing changes twice daily. What would be an appropriate measurable short-term outcome for this client?
Correct Answer: C
Rationale: The client having no fever or purulent discharge in 3 days is a realistic measurable goal. The wound is large and will not heal within the time frame of discharge. It is unrealistic to have an outcome that the client will be able to change a dressing after a surgical procedure. Dressing changes twice a day is a nursing intervention.
Question 2 of 5
The RN determines the interventions for a client with pneumonia and writes them in the written plan as nursing interventions. What would be an appropriate nursing intervention for this client?
Correct Answer: B
Rationale: Nursing interventions are specific nursing directions so that all healthcare team members understand exactly what to do for the client. Different people are likely to interpret a vague nursing order such as 'Encourage fluids' differently, resulting in inconsistent care. The other answers are not specific and are open to different interpretations. Forcing a client to do anything is not therapeutic or ethical for nurses.
Question 3 of 5
A client is being admitted to the medical floor, and the RN is too busy to do the full assessment. The RN delegates the LPN to care for the client until the RN can see the client. What function is within the scope of practice for the LPN?
Correct Answer: A
Rationale: The role of the LPN in the nursing process for assessment is to gather data, perform assessment, and identify the client's strengths. Drawing conclusions and using judgment to make a diagnosis, establishing priorities, and managing the client's care are within the RN scope of practice.
Question 4 of 5
A nurse is creating a plan of care and has identified several problems for the client including a collaborative problem. Which statement distinguishes a collaborative problem from a problem-focused nursing diagnosis?
Correct Answer: B
Rationale: Collaborative problems denote complications with a physiologic origin and differ from nursing diagnoses, which address client responses to various circumstances and are managed by nursing interventions. Related risk factors and defining characteristics are parts of a nursing diagnosis, not a collaborative problem. A nursing diagnosis describes a client's response to a physiologic condition or the environment and can be addressed by nursing interventions (independent or health care provider prescribed). Secondary risk factors can provide a more in-depth explanation of the cause of a problem in a nursing diagnosis. Collaborative problems do not have secondary risk factors.
Question 5 of 5
An RN has developed a plan of care for a client and shares the plan with the LPN. Which intervention(s) can the LPN perform in the implementation phase for this client? Select all that apply.
Correct Answer: A,B,E
Rationale: The role of the LPN in the implementation phase is to provide basic therapeutic and preventive nursing measures, provide client education, and record information. Exchanging information with the prescribing provider and making referrals are within the scope of practice of an RN.