What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? Select all that apply.

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ATI LPN Fundamentals Proctored Exam 2024 Questions

Question 1 of 5

What interventions should the nurse implement in caring for a client with diabetes insipidus (DI) following a head injury? Select all that apply.

Correct Answer: A

Rationale: For diabetes insipidus (DI) post-head injury, providing fluids (A) prevents dehydration from polyuria. Increasing urine specific gravity (B) contradicts DI's dilute urine. Erythromycin (C) is unrelated. Neurological changes (D) are monitored but secondary. A is correct. Rationale: Fluid replacement matches DI's excessive output, a primary intervention per endocrine care standards, maintaining hydration.

Question 2 of 5

The nurse is caring for a client who sustained a traumatic brain injury. Which intervention should the nurse perform to prevent an increase in intracranial pressure (ICP)?

Correct Answer: B

Rationale: Maintaining HOB at 30 degrees (B) reduces ICP by aiding venous drainage. Hourly suctioning (A) or coughing (C) raises ICP. Fluid bolus (D) may worsen it. B is correct. Rationale: Elevation optimizes cerebral perfusion pressure while minimizing ICP, per brain injury care standards, unlike actions that increase intrathoracic pressure.

Question 3 of 5

When documenting an assigned client's record during and at the end of the shift, the nurse must keep in mind which of the following facts?

Correct Answer: C

Rationale: Documentation is a cornerstone of nursing practice, and recognizing the chart as a legal document is paramount. It serves as the primary evidence of care provided, protecting the nurse in legal disputes by detailing actions, observations, and client responses. If called to court, this record may be the only defense against claims of negligence or improper care, making accuracy and completeness essential. Brevity might compromise detail, undermining its legal value, while specific formats like SOAP enhance clarity but aren't the core issue. Hourly documentation isn't universally required unless specified by policy; the focus is on capturing significant events. This understanding ensures nurses document with precision, safeguarding both client care and professional accountability in a legal context.

Question 4 of 5

When you discover an electrical fire and decide you need a fire extinguisher, you will need to find a fire extinguisher that is rated for which class of fire?

Correct Answer: C

Rationale: An electrical fire requires a Class C extinguisher, designed for energized electrical equipment like appliances or wiring. Class A suits ordinary combustibles (wood), Class B handles flammable liquids, and Class E isn't standard (often confused with electrical but not U.S.-classified). Using a Class C extinguisher, typically with non-conductive agents like carbon dioxide, ensures safety by avoiding shock while extinguishing. This choice protects both the nurse and client in a healthcare setting, aligning with fire safety protocols.

Question 5 of 5

When the physician telephones to order a therapy such as a medication for the client of a student nurse, who is the best person to take this telephone order?

Correct Answer: A

Rationale: Hospital policy dictates who takes telephone orders, ensuring legal and safety compliance, typically a licensed nurse, not a student or instructor alone. This standard protects clients from errors by untrained personnel, aligning with nursing scope and institutional rules for accurate order execution.

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