PN Fundamentals 2023

Extract:

Question 1 of 5

A nurse is caring for a client who refuses their morning dose of antihypertensive medication. The client tells the nurse, 'I'm not going to take this medication because it makes me sick and dizzy.' Which of the following actions should the nurse take first?

A. Document the refusal in the client's medical record. B. Return the medication to the medication cabinet. C. Inform the client of the potential consequences of their refusal. D. Notify the provider of the client's refusal.

Correct Answer: C

Rationale: Informing about consequences first respects autonomy and may encourage compliance.

Question 2 of 5

A nurse is preparing to set up a sterile field to change a sterile dressing on a client's abdominal wound. Identify the sequence of steps the nurse should take.

Order the Items

Source Container

Grasp the outermost flap of the sterile kit while opening away from the body.

Open the innermost lower flap of the sterile kit while standing away from the sterile field.

Open each side flap of the sterile kit individually while pulling to the side.

Prepare a dry work surface above the waist level.

Open the outside cover of the sterile kit and remove the dust cover.

Correct Answer: D,E,A,C,B

Rationale: D: Set up surface. E: Remove cover. A: Open outermost flap. C: Open side flaps. B: Open innermost flap maintains sterility.

Question 3 of 5

A nurse is coordinating care of a group of clients with an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

A. Measure the intake and output of a client who has received furosemide. B. Assess the pain level of a client who has received acetaminophen. C. Reinforce teaching with a client about crutch-gait walking. D. Check a client's peripheral IV site for redness or swelling.

Correct Answer: A

Rationale: Measuring intake and output is within the APâ€™s scope and appropriate for delegation.

Question 4 of 5

A nurse is preparing to perform a fecal occult blood test of stool specimens for a client. Which of the following actions should the nurse plan to take?

A. Repeat the test three times using the same stool specimen. B. Wear sterile gloves when handling the stool specimen. C. Have the client defecate into a bedpan that contains a small amount of water. D. Ensure that the stool specimen does not contain urine.

Correct Answer: D

Rationale: Ensuring no urine contamination maintains specimen integrity for accurate testing.

Question 5 of 5

A nurse is assisting with feeding a client who has had a stroke. Which of the following findings should the nurse identify as a manifestation of dysphagia?

A. Rapid chewing B. Garbled voice C. Sneezing D. Increased hunger

Correct Answer: B

Rationale: A garbled or 'wet' voice indicates difficulty swallowing, a sign of dysphagia.

PN Fundamentals 2023 | Nurselytic

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ATI LPN

ATI LPN