Nokea
An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
- A. Check the carotid pulse
- B. Deliver 5 abdominal thrusts
- C. Give 2 rescue breaths
- D. Open the client's airway
Correct Answer: D
Rationale: In this scenario, the priority is to ensure the client has a clear airway to facilitate breathing. After verifying unresponsiveness and calling for help, the nurse should open the client's airway to aid in maintaining ventilation. Checking the carotid pulse (Choice A) may be important but comes after ensuring a clear airway. Delivering abdominal thrusts (Choice B) is indicated for choking, not for an unresponsive client. Giving rescue breaths (Choice C) is also important but only after the airway has been established.
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A postoperative client is reporting pain at a level of 2 on a scale of 0 to 10. What is an indication that the client understands pain management?
- A. It might help me to listen to music while lying in bed.
- B. I should try to sleep as much as possible to avoid pain.
- C. I don't need pain medication if my pain is only at a 2.
- D. I will try to use the pain management techniques suggested by the nurse.
Correct Answer: A
Rationale: The correct answer is A because understanding pain management involves considering non-pharmacological approaches, such as listening to music for relaxation and comfort. Choice B is incorrect as excessive sleep may not be an effective pain management strategy. Choice C is incorrect because pain medication may still be necessary even if pain levels are low. Choice D is not the best answer, as it simply states following the nurse's suggestions without demonstrating an understanding of personalized pain management techniques.
A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy?
- A. Collaborating with providers to perform obesity screenings during routine office visits.
- B. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity.
- C. Providing specialized intraoperative training in surgical treatments for obesity.
- D. Educating acute care nurses about postoperative complications related to obesity.
Correct Answer: A
Rationale: The correct answer is A: Collaborating with providers to perform obesity screenings during routine office visits. This is a primary health care strategy as it focuses on prevention and early detection, which are key components of managing obesity. Screening during routine visits allows for timely identification of obesity and related health risks, enabling early intervention. Choices B, C, and D do not align with primary health care strategies for obesity. Ensuring availability of specialized beds, providing intraoperative training, and educating about postoperative complications are more focused on secondary and tertiary levels of care, rather than primary prevention and early detection.
A client with congestive heart failure (CHF) is receiving furosemide (Lasix). Which laboratory value should the LPN monitor closely while the client is taking this medication?
- A. Sodium
- B. Potassium
- C. Calcium
- D. Magnesium
Correct Answer: B
Rationale: The LPN should monitor potassium levels closely while the client is taking furosemide (Lasix) due to the medication's potential to cause hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss through increased urine output. Hypokalemia can result in serious complications such as cardiac dysrhythmias. Monitoring sodium levels (choice A) is important but not as critical as monitoring potassium in this context. Calcium (choice C) and magnesium (choice D) levels are not typically affected by furosemide and are not the priority for monitoring in this scenario.
A charge nurse on an acute care unit is planning care for a client. Which of the following actions should the nurse take to promote the client's continuity of care?
- A. Plan to assign the client a different nurse each shift
- B. Limit the number of interdisciplinary team members involved in managing the client's care
- C. Request that the client complete a satisfaction survey at discharge
- D. Start discharge planning on the day of admission
Correct Answer: D
Rationale: Starting discharge planning on the day of admission is crucial to ensuring a smooth transition and continuity of care for the client. It allows for early identification of needs, coordination of services, and timely interventions. Assigning a different nurse each shift (Choice A) can disrupt continuity of care and lead to inconsistencies in the client's treatment. Limiting the number of interdisciplinary team members (Choice B) may hinder comprehensive care coordination. Requesting a satisfaction survey at discharge (Choice C) focuses more on feedback rather than proactive care planning and coordination.
During auscultation of the anterior chest wall of a client newly admitted to a medical-surgical unit, what type of breath sounds should a nurse expect to hear?
- A. Normal breath sounds
- B. Adventitious breath sounds
- C. Absent breath sounds
- D. Diminished breath sounds
Correct Answer: A
Rationale: During auscultation of the chest, normal breath sounds are the expected findings in a client who is newly admitted without respiratory complaints. Normal breath sounds indicate proper airflow through the airways without any abnormalities. Adventitious breath sounds (Choice B) refer to abnormal lung sounds such as crackles or wheezes, which are indicative of underlying respiratory issues. Absent breath sounds (Choice C) suggest a lack of airflow to a particular lung area, which could be due to conditions like pneumothorax. Diminished breath sounds (Choice D) indicate reduced airflow or consolidation in a specific lung region, often seen in conditions like pleural effusion or pneumonia. Therefore, in a newly admitted client without respiratory complaints, the nurse should expect to hear normal breath sounds during auscultation.