ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 3 : The Nursing Process Questions
Question 1 of 5
The LPN is assisting with the admission of a client scheduled for surgery the next day. What role does the LPN have in the planning phase of the nursing process?
Correct Answer: D
Rationale: The role of the LPN allows for the contribution of the development of care plans. The other answers are within the scope of practice of an RN.
Question 2 of 5
A client has a nursing diagnosis of altered skin integrity related to prescribed bed rest and decreased mobility of the lower extremities as evidenced by a reddened area on heels and fluid-filled blister on sacrum. Which part of this nursing diagnosis is considered the cause?
Correct Answer: C
Rationale: The cause portion of the nursing diagnosis includes the factors contributing to the problem; in this case, they are 'prescribed bed rest and decreased mobility of the lower extremities.' Impaired skin integrity is the stated problem, and the reddened area on the heels and the fluid filled blister are the defining characteristics that describe the problem.
Question 3 of 5
The LPN is collecting data so that the RN may develop the plan of care for the client. What is the importance of accurate gathering of baseline data?
Correct Answer: B
Rationale: The client database includes all the information obtained from the medical and nursing history, physical examination, and diagnostic studies. Baseline data serve as a comparison for future signs and symptoms and provide a reference for determining if a client's health is improving. The physician does not use the care plan for the diagnosis.
Question 4 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 5 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.