ATI LPN
Chapter 14 Organizing Patient Care Questions Questions
Question 1 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 2 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 3 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.
Question 4 of 5
The nurse is assessing a client who reports drinking a quart of vodka daily. The client says, 'I think I have a little bit of a drinking problem.' Which response by the nurse is most therapeutic?
Correct Answer: B
Rationale: Tell me what you mean by a drinking problem' is most therapeutic. It encourages exploration, building trust, per communication standards. Judging , agreeing , or reporting hinder openness. B supports assessment, making it the best response.
Question 5 of 5
The nurse is caring for a client who had a total hip replacement yesterday. Which action should the nurse take to prevent dislocation of the prosthesis?
Correct Answer: A
Rationale: Keeping legs abducted with a pillow prevents dislocation post-hip replacement. It maintains alignment, reducing adduction risk, per protocol. Early ambulation is later, flexion risks dislocation, and instruction is secondary. A ensures stability, making it best.