Practice Question
A nurse is assisting with the care of a client on the medical unit.
Answer Choices:
Correct Answer:
Measure daily weight.
Rationale:
Measure daily weight:
🔷Daily weight is a routine, non-invasive measurement that can be safely delegated to assistive personnel (AP).
🔷It is especially important in a client with dehydration, since weight change is a sensitive indicator of fluid balance status.
🔷The nurse remains responsible for interpreting the results and correlating them with lab values and intake/output.
Ambulate with gait belt:
🔷Ambulation with a gait belt is within the scope of APs because it is a basic mobility and safety task.
🔷This client is at risk of orthostatic hypotension and falls due to dehydration, so AP assistance helps maintain safety.
🔷The nurse delegates the activity, but ensures the AP knows how to use the gait belt properly and when to report dizziness or unsteadiness.
Measure output:
🔷Monitoring urine and stool output is a standard task for APs and provides essential data for assessing hydration status.
🔷This information contributes to the nurse’s evaluation of fluid balance and kidney perfusion.
🔷APs can collect and record the measurements, while the nurse interprets trends in output relative to intake and lab results.
Assist client on bedpan:
🔷Helping a client with elimination needs is a basic task that falls within the AP’s role.
🔷It promotes comfort and dignity, while also facilitating accurate measurement of intake and output.
🔷The nurse ensures correct documentation and assesses the characteristics of the stool if clinically significant (e.g., watery, bloody).
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This question is from PN Fundamentals 2023 Exam Sept which contains 72 questions.
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A nurse in an outpatient surgical center is assisting in the care of a client.
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A nurse enters a dienes room and finds the client face down on the floor. Which of the following actions should the nurse take first?
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A nurse is applying cold therapy to a client's face following oral surgery. The nurse should identify that which of the following is a therapeutic effect of cold therapy?
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A nurse is collecting data about a client's gastrointestinal system. While auscultating the abdomen, the nurse notes loud growling sounds. When documenting these findings. the nurse should use which of the following terms?
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Question Details
- Category: LPN Nursing Exam(s)
- Subcategory: LPN ATI Exams
- Domain: Fundamentals of Nursing
- Answer Choices: 7