ATI LPN
Chapter 14 Organizing Patient Care Questions Questions
Question 1 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 2 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 3 of 5
A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states 'I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.' The nurse should understand that
Correct Answer: B
Rationale: The client has a right to know about medications . Autonomy entitles education on use and side effects, per ethics. Referral , nurse discretion , or complication risk undermine this. B respects rights, making it correct.
Question 4 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 5 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.