ATI LPN
Patient Comfort Questions Questions
Question 1 of 5
What do you think is the most important nursing order in a client with major head trauma who is about to receive bolus enteral feeding?
Correct Answer: A
Rationale: Measuring intake and output is the most important order for a head trauma client receiving bolus enteral feeding, per the document. Enteral feeds, being hyperosmotic, draw fluid into the vascular bed, risking diuresis. Monitoring I&O ensures fluid balance, critical with head injuries where cerebral edema is a concern. Albumin levels assess nutrition long-term, not acutely. Glucose monitoring is relevant but secondary to fluid status. Increasing feeding could worsen imbalance. I&O directly addresses immediate risks, guiding adjustments to prevent complications like dehydration or overhydration, making it the priority.
Question 2 of 5
The nurse is caring for a 7 year-old with acute glomerulonephritis (AGN). Findings include moderate edema and oliguria. Serum blood urea nitrogen and creatinine are elevated. What dietary modifications are most appropriate?
Correct Answer: B
Rationale: Decreased sodium and potassium is most appropriate for AGN with edema, oliguria, and elevated BUN/creatinine. Sodium restriction reduces fluid retention, easing edema, while potassium restriction prevents hyperkalemia from reduced renal clearance. Decreased carbs/fat is irrelevant to renal function. Increased potassium/protein risks toxicity and uremia. Increased sodium/fluids worsens edema. B aligns with AGN management, supporting renal recovery, making it the best modification.
Question 3 of 5
A nurse is working with a client in an extended care facility. Which bed position is preferred for a client, who is at risk for falls, as part of a prevention protocol?
Correct Answer: D
Rationale: Bed in lowest position, wheels locked, against the wall is preferred for fall prevention. Low height minimizes injury risk, locked wheels ensure stability, and wall placement reduces access points. Four rails are a restraint, not prevention. Lower rails or bent knees don't optimize safety. D follows safety protocols, reducing fall risk, making it the best position.
Question 4 of 5
The RN delegates the task of taking vital signs of all the clients on the medical-surgical unit to an unlicensed assistive personnel (UAP). Specific written and verbal instructions are given to not take a post-mastectomy client's blood pressure on the left arm. Which of these statements is most immediately accurate?
Correct Answer: D
Rationale: The UAP is responsible for following instructions . Delegation was clear; accountability lies with UAP adherence. RN accountability exists, delegation was appropriate (B false), and UAP isn't under RN license . D ensures task execution, making it accurate.
Question 5 of 5
Which one of these tasks can be safely delegated to a practical nurse (PN)?
Correct Answer: C
Rationale: Providing stoma care for a well-functioning ostomy can be delegated to a PN. Routine care fits PN scope, unlike assessing new ileostomy , complex colostomy , or teaching , which need RN skills. C ensures safe delegation.