ATI LPN
PN ATI Capstone Maternal Newborn
1. A client is experiencing urinary incontinence, and a nurse is providing care. Which of the following recommendations should the nurse include in the teaching plan for this client?
- A. Drink large amounts of water before bedtime
- B. Perform Kegel exercises regularly
- C. Limit fiber intake in the diet to avoid bowel irritation
- D. Increase intake of caffeinated and carbonated beverages
Correct answer: B
Rationale: The correct recommendation for a client experiencing urinary incontinence is to perform Kegel exercises regularly. These exercises help strengthen the pelvic floor muscles, improving bladder control and reducing urinary incontinence. Option A is incorrect because drinking large amounts of water before bedtime can worsen urinary incontinence by increasing urine production. Option C is incorrect as fiber is important for bowel health and limiting it may not be beneficial for the client. Option D is incorrect as caffeinated and carbonated beverages can irritate the bladder and worsen urinary incontinence, so they should be avoided.
2. A home health nurse is providing teaching to a family of a client who has seizure manifestations as a result of an inoperable brain tumor. What intervention should the nurse include in the teaching?
- A. Administer antiseizure medications promptly.
- B. Use oral airway devices during seizures.
- C. Pad the side rails of the bed.
- D. Apply restraints during the seizure to prevent injury.
Correct answer: C
Rationale: The correct intervention the nurse should include in the teaching is to pad the side rails of the bed. By padding the side rails, the nurse can help prevent injury if the patient experiences a seizure. Administering antiseizure medications promptly (Choice A) is typically the responsibility of a healthcare provider or according to a prescribed schedule. Using oral airway devices during seizures (Choice B) can pose risks and should be managed by healthcare professionals. Applying restraints during a seizure (Choice D) is not recommended as it can lead to further injury and complications.
3. A provider has written a do not resuscitate (DNR) order for a client who is comatose and does not have advance directives. A member of the client’s family says, 'I wonder when the doctor will tell us what’s going on.' Which of the following actions should the nurse take first?
- A. Request that the provider provide more information to the family.
- B. Refer the family to a support group for grief counseling.
- C. Offer to answer questions that family members have.
- D. Ask the family what the provider has discussed with them.
Correct answer: D
Rationale: The correct action for the nurse to take first is to ask the family what the provider has discussed with them. This allows the nurse to clarify any misunderstandings and ensures that the family is fully informed before providing further information. Option A is not the best choice because it assumes the need for more information without first understanding what has already been communicated. Option B is premature as the family may not be ready for grief counseling at this stage. Option C, although a good general practice, is not the most appropriate immediate action in this situation where clarifying existing information is crucial.
4. A client with a history of asthma is being cared for by a nurse. Which of the following should the nurse monitor?
- A. Heart rate
- B. Respiratory status
- C. Blood glucose levels
- D. Liver function
Correct answer: B
Rationale: The correct answer is B: Respiratory status. When caring for a client with asthma, it is essential to monitor their respiratory status to detect any changes in breathing or signs of airway obstruction. Monitoring heart rate (choice A) may be important in some situations but is not the priority when managing asthma. Blood glucose levels (choice C) and liver function (choice D) are not directly related to asthma and would not be the primary focus of monitoring for a client with this condition.
5. A child is prescribed ferrous sulfate. Which of the following instructions should the nurse include?
- A. Take with meals
- B. Take at bedtime
- C. Take with a glass of milk
- D. Take with a glass of orange juice
Correct answer: D
Rationale: The correct answer is to take ferrous sulfate with a glass of orange juice. Vitamin C, found in orange juice, enhances iron absorption. Taking iron with milk (choice C) is not recommended as it reduces iron absorption. Taking it with meals (choice A) can hinder its absorption due to other food components. Taking it at bedtime (choice B) doesn't affect absorption but might cause gastrointestinal upset in some individuals.
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