Nokea
When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?
- A. Immediately after exhalation.
- B. During the inhalation.
- C. At the end of three inhalations.
- D. Immediately after inhalation.
Correct Answer: B
Rationale: The correct answer is B: 'During the inhalation.' Administering the medication while inhaling ensures proper delivery to the lungs. Inhaling the medication allows it to reach the lungs effectively for optimal therapeutic benefit. Choices A, C, and D are incorrect because administering the medication after exhalation or at the end of inhalations may result in improper drug delivery and reduced therapeutic effects.
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A patient's hygiene schedule of bathing and brushing teeth is largely influenced by family customs. For which age group is the nurse most likely providing care?
- A. Adolescent
- B. Preschooler
- C. Older adult
- D. Adult
Correct Answer: B
Rationale: The correct answer is B: Preschooler. Family customs have a significant impact on hygiene practices during childhood, especially in the early years. Preschoolers are at an age where they are learning and forming habits, and family customs play a crucial role in establishing routines such as bathing and brushing teeth. Adolescents, older adults, and adults are more likely to have established their own hygiene routines that may not be as heavily influenced by family customs as in early childhood. Therefore, the nurse is most likely providing care to a preschooler in this scenario.
A nurse is preparing an infusion for a client who was hospitalized with deep-vein thrombosis. The orders read: 25,000 units of heparin in 250 mL of 0.9% sodium chloride to infuse at 800 units/hr. At what rate should the nurse set the infusion pump?
- A. 8 mL/hr
- B. 10 mL/hr
- C. 12 mL/hr
- D. 15 mL/hr
Correct Answer: A
Rationale: To calculate the infusion rate, use the formula: (Desired units/hr / Total units) Volume. In this case, it would be (800 units/hr / 25,000 units) 250 mL = 8 mL/hr. Therefore, the nurse should set the infusion pump at 8 mL/hr. Choice B, 10 mL/hr, is incorrect because it does not match the calculated rate. Choices C and D, 12 mL/hr and 15 mL/hr respectively, are also incorrect as they do not align with the correct calculation based on the provided data.
The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?
- A. Swelling and redness in the affected leg
- B. Pain in the affected leg
- C. Warmth and tenderness in the affected leg
- D. A positive Homans' sign
Correct Answer: D
Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.
A client who is 5'5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the LPN to include during the preoperative assessment?
- A. What is your daily calorie consumption?
- B. What vitamin and mineral supplements do you take?
- C. Do you feel that you are overweight?
- D. Will a clear liquid diet be okay after surgery?
Correct Answer: B
Rationale: During the preoperative assessment, it is crucial for the LPN to inquire about the client's intake of vitamin and mineral supplements. This is important because certain supplements can have effects on coagulation, wound healing, and overall surgical outcomes. Asking about daily calorie consumption (Choice A) is not as pertinent as inquiring about vitamin and mineral supplements in this context. Questioning the client about feeling overweight (Choice C) may not directly impact the surgical outcome compared to the effects of supplements. Inquiring about the post-surgery diet (Choice D) is relevant but not as critical as understanding the client's supplement intake.
A client in the terminal stage of cancer is crying. What action should the nurse take?
- A. Sit and hold the client's hand
- B. Encourage the client to talk about their feelings
- C. Leave the client alone to cry
- D. Ignore the client's crying
Correct Answer: A
Rationale: In situations where a client is in the terminal stage of cancer and crying, it is essential for the nurse to provide comfort and support. Sitting with the client and holding their hand can offer a sense of presence and emotional support, showing empathy and understanding. Encouraging the client to talk about their feelings (choice B) is also important, but initially, non-verbal support through physical presence can be comforting. Leaving the client alone to cry (choice C) can make the client feel abandoned and unsupported during a vulnerable moment. Ignoring the client's crying (choice D) is not appropriate and lacks compassion and empathy, which are crucial in end-of-life care.