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 nurse is caring for a newborn in the nursery following a circumcision. The newborn's grandparent, who does not have an identification bracelet, requests to take the newborn to his mother's room. What action should the nurse take?
- A. Notify security.
- B. Respectfully deny the grandparent’s request.
- C. Contact the mother for verification.
- D. Escort the grandparent and newborn to the room.
Correct answer: B
Rationale: The correct action for the nurse to take is to respectfully deny the grandparent's request. In healthcare settings, strict security protocols are in place to ensure the safety of newborns. Only individuals with proper identification bracelets are allowed to transport newborns to prevent unauthorized individuals from taking them. Contacting the mother for verification would be time-consuming and may not be feasible immediately. Escorting the grandparent and newborn without proper identification would violate security protocols and compromise the newborn's safety. Notifying security should be done only if there is a threat or concern for safety, which is not the case in this scenario. Therefore, the best course of action is for the nurse to respectfully deny the grandparent's request to uphold the safety and security measures in place.
3. A charge nurse is evaluating the time management skills of a newly licensed nurse. The charge nurse should intervene when the newly licensed nurse does which of the following?
- A. Re-evaluates priorities halfway through the shift
- B. Delegates changing a sterile dressing to a licensed practical nurse
- C. Groups activities for the same client
- D. Works on several tasks simultaneously
Correct answer: D
Rationale: The correct answer is D. Working on several tasks simultaneously may lead to errors due to divided attention and lack of focus. It is important for nurses to prioritize tasks and complete them one at a time to ensure thoroughness and accuracy. Choices A, B, and C are appropriate time management strategies. Re-evaluating priorities, delegating tasks appropriately, and grouping activities for the same client can help improve efficiency and quality of care.
4. A nurse overhears two assistive personnel (APs) discussing a client in a hospital cafeteria, using the client’s name and discussing details of the diagnosis. Which of the following actions should the nurse take first?
- A. Report the APs' behavior to the supervisor
- B. Complete an incident report regarding the APs' conversation
- C. Provide the APs with written documentation on confidentiality
- D. Tell the APs to discontinue their conversation
Correct answer: D
Rationale: The correct action for the nurse to take first is to tell the APs to discontinue their conversation. By stopping the conversation immediately, the nurse addresses the breach of client confidentiality on the spot. This action is crucial to protect the client's privacy and confidentiality. While further steps such as reporting the behavior or providing education on confidentiality may be necessary, the immediate priority is to stop the inappropriate discussion. Reporting the behavior to the supervisor or completing an incident report can come after the immediate issue is addressed. Providing written documentation on confidentiality may be helpful but is not the most urgent action needed in this situation.
5. A nurse is teaching about foot care to a client who has diabetes mellitus (DM). What statement indicates understanding?
- A. I should wear my slippers whenever I am out of bed
- B. I can walk barefoot at home
- C. I should apply lotion between my toes
- D. I can soak my feet in warm water
Correct answer: A
Rationale: The correct answer is A. Wearing slippers or shoes when out of bed is crucial for clients with diabetes as it protects the feet from injury. Walking barefoot, as mentioned in option B, can increase the risk of cuts, sores, and infections in diabetic patients. Applying lotion between the toes, as stated in option C, can lead to maceration and increase the risk of fungal infections. Similarly, soaking feet in warm water, as mentioned in option D, can cause skin breakdown and should be avoided by diabetic patients.
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