ATI LPN
Chapter 14 Organizing Patient Care Questions Questions
Question 1 of 5
A client has developed thrombophlebitis of the left leg. Which nursing intervention should be given the highest priority?
Correct Answer: A
Rationale: Elevation reduces swelling and promotes venous return, the primary intervention.
Question 2 of 5
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
Correct Answer: A
Rationale: High Fowler's promotes lung expansion and reduces cardiac workload in CHF.
Question 3 of 5
Which position is recommended for a patient experiencing difficulty breathing?
Correct Answer: C
Rationale: Fowler's position, where the head of the bed is elevated, is ideal for patients with breathing difficulties because it maximizes lung expansion and eases respiratory effort. Gravity assists the diaphragm's movement, reducing pressure on the chest and improving oxygen intake, which is critical in conditions like dyspnea. Prone position (lying face down) may help specific cases like ARDS but isn't generally recommended for most breathing issues. Supine position (flat on back) can restrict lung expansion, worsening the problem. Trendelenburg position (head lower than feet) is used for circulatory issues, not respiratory support, and could exacerbate breathing difficulties. Fowler's position aligns with physiological needs for better air exchange, making it the nurse's go-to choice.
Question 4 of 5
Which patient population is at a higher risk of pressure ulcers?
Correct Answer: C
Rationale: Elderly individuals with limited mobility are at higher risk for pressure ulcers due to age-related skin thinning, reduced circulation, and prolonged pressure on bony areas from immobility. These factors impair skin integrity, making it prone to breakdown. Young adults typically have resilient skin and mobility, lowering their risk. Athletes, with strong circulation and muscle tone, are less susceptible unless injured. Regular exercisers maintain healthy blood flow, reducing risk further. The elderly, especially when bedridden or chair-bound, face constant pressure and shear forces, compounded by potential malnutrition or chronic illness, necessitating vigilant nursing care like repositioning and pressure-relieving devices.
Question 5 of 5
Which action demonstrates proper hand hygiene for a nurse before and after patient care?
Correct Answer: C
Rationale: Washing hands with soap and water for at least 20 seconds (ideally 40-60 per CDC guidelines) before and after patient care removes pathogens effectively, breaking the chain of infection. Wiping on a towel doesn't kill germs and may spread them. Using sanitizer only after care skips pre-care protection, risking contamination to the patient soap is superior for visible dirt or C. diff. Shaking hands for rapport, while friendly, isn't hygiene-focused and could transmit microbes. This rigorous washing is a fundamental nursing practice, safeguarding both patient and nurse from healthcare-associated infections.