ATI LPN
Chapter 14 Organizing Patient Care Questions Questions
Question 1 of 5
The nurse is planning care for a client with a cerebral vascular accident (CVA). Which of the following measures planned by the nurse would be most effective in preventing skin breakdown?
Correct Answer: C
Rationale: Repositioning every two hours is most effective for preventing skin breakdown in a CVA client. Immobility from paralysis increases pressure on bony prominences, risking tissue ischemia and pressure ulcers. Regular repositioning relieves this pressure, enhances blood flow, and aligns with evidence-based prevention strategies. Wheelchair use aids mobility but doesn't address constant pressure relief. Padding helps but is less effective without movement. Massaging reddened areas can worsen damage if circulation is poor. C is proactive, foundational to skin integrity, and standard in immobile patients, making it the best choice.
Question 2 of 5
Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?
Correct Answer: C
Rationale: Suggesting iron-rich, easy foods is delegable to a UAP. It's a supportive task within scope, aiding nutrition without assessment. Skin turgor , testing , and mental status require RN judgment. C enhances care safely, making it appropriate.
Question 3 of 5
A client has had a tracheostomy for 2 weeks after a motor vehicle accident. Which task could the RN safely delegate to unlicensed assistive personnel (UAP)?
Correct Answer: B
Rationale: Changing trach ties can be safely delegated to a UAP. It's a routine task within scope, unlike teaching , monitoring SOB , or dressing care , which require RN skills. B ensures safety, making it appropriate.
Question 4 of 5
Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items?
Correct Answer: C
Rationale: Deeper amber, almost brown urine requires nurse action. It suggests dehydration or infection, urgent in a catheterized client, needing assessment. Sleep issues , meal service , and slow days are less acute. C prioritizes safety, making it the key data.
Question 5 of 5
The family of a 6 year-old with a fractured femur asks the nurse if the child's height will be affected by the injury. Which statement is true concerning long bone fractures in children?
Correct Answer: B
Rationale: Epiphyseal fractures often interrupt growth is true. The epiphyseal plate, critical for lengthening, is vulnerable; damage alters height. Periosteum heals well, quick healing doesn't prevent this, and blood supply doesn't negate plate injury. B reflects physiology, making it correct.