ATI LPN
Chapter 14 Organizing Patient Care Questions Questions
Question 1 of 5
A client tells the nurse, 'I have something very important to tell you if you promise not to tell.' The best response by the nurse is
Correct Answer: B
Rationale: I can't make such a promise' is best. Confidentiality has limits (e.g., safety); this maintains trust while setting boundaries, per ethics. Documentation , conditional , or team reporting overstep or confuse. B balances honesty, making it the top response.
Question 2 of 5
A client with Guillain Barre is in a nonresponsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
Correct Answer: A
Rationale: Comatose, breathing unlabored' most accurately describes a nonresponsive Guillain-Barré client with stable vitals. Coma fits unresponsiveness, independent breathing notes stability. GCS 8 or 13 assumes scores not given, sleeping understates severity. A reflects condition, making it precise.
Question 3 of 5
A client is admitted with infective endocarditis (IE). Which finding would alert the nurse to a complication of this condition?
Correct Answer: A
Rationale: Dyspnea alerts to an IE complication, like heart failure or emboli, needing urgent care. Murmur is a symptom, rash and hemorrhage less acute. A signals distress, making it priority.
Question 4 of 5
A child is injured on the school playground and appears to have a fractured leg. The first action the school nurse should take is
Correct Answer: C
Rationale: Assessing the child and injury is the first action. It determines severity, guiding care, per nursing process. Calling , immobilizing , or compresses follow. C ensures informed response, making it priority.
Question 5 of 5
A 14 year-old client has viral pneumonia and is receiving acetaminophen (Tylenol) for fever control. Which instruction should the nurse include when teaching the client's parents?
Correct Answer: C
Rationale: Check with the doctor before giving OTC cold preparations' is key. Viral pneumonia doesn't benefit from cough suppressants, and interactions with acetaminophen need oversight, per safety. Fever threshold is vague, alternating meds risks overdose, and fixed dosing lacks flexibility. C prevents harm, making it the best instruction.