ATI LPN
NCLEX Questions Patient Centered Care Questions
Question 1 of 5
Which of the following would be a priority nursing diagnosis for a 73-year-old male patient with heart failure?
Correct Answer: C
Rationale: Using ABCs (airway, breathing, circulation), activity intolerance (C) due to oxygen imbalance is the priority in heart failure, affecting energy conservation. A, B, and D are concerns but lower priority, making C the focus.
Question 2 of 5
A nursing intervention directs the patient to be turned every 2 hours to prevent skin breakdown from immobility. Assessment findings on new reddened areas on the lateral aspects of the right knee and ankle are obtained. What is the most appropriate way for these findings to be used when the care plan is evaluated?
Correct Answer: D
Rationale: Evaluation adjusts the plan based on outcomes (D); redness after 2-hour turns indicates a need for hourly turns to prevent breakdown. A (documentation) doesn’t adjust care, B is incorrect (problem is actual), and C (calling MD) isn’t independent, making D the best response.
Question 3 of 5
A nurse is caring for a client who has urinary leakage due to nerve damage following a spinal cord injury. The nurse should identify that the client is experiencing which of the following types of urinary incontinence?
Correct Answer: A
Rationale: Reflex incontinence occurs due to involuntary bladder contractions from nerve damage, such as after a spinal cord injury, causing the bladder to empty without the client's control. Stress incontinence (B) involves leakage from physical pressure, urge incontinence (C) involves a sudden need to urinate, and overflow incontinence (D) results from incomplete emptying, none of which align with nerve damage-related involuntary emptying.
Question 4 of 5
The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission's main objective?
Correct Answer: C
Rationale: Assessing respirations when administering opioids directly addresses safety by preventing respiratory depression, aligning with The Joint Commission’s focus. Range-of-motion exercises (A), meal intake (B), and delegation (D) are valuable but not primarily safety-focused.
Question 5 of 5
A client is scheduled for a mastectomy. As she is about to receive the preoperative medication, she tells the nurse that she does not want to have her breast removed but wants a lumpectomy. Which response indicates that the nurse is acting as a client advocate?
Correct Answer: B
Rationale: Calling the surgeon to explain options supports the client’s right to be informed and change her treatment plan, exemplifying advocacy. Reassurance (A), prayer (C), or a survivor visit (D) do not address her expressed desire for a different procedure.