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A client reports increased pain following physical therapy. Which of the following questions should be asked to assess the quality of the pain?
- A. Is your pain sharp or dull?
- B. Is your pain constant or intermittent?
- C. On a scale from 1 to 10, how severe is your pain?
- D. Where exactly is your pain located?
Correct Answer: A
Rationale: Correct Answer: A. Asking whether the pain is sharp or dull helps in determining the quality of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate chronic issues. Choices B, C, and D focus on different aspects of pain assessment. Option B pertains to the pattern of pain, either constant or intermittent. Option C addresses the severity of pain on a numerical scale. Option D inquires about the location of pain. While all these questions are essential in pain assessment, when specifically evaluating the quality of pain, distinguishing between sharp and dull sensations is crucial.
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A healthcare professional is preparing to inject heparin subcutaneously for a client who is postoperative. Which of the following actions should the healthcare professional take?
- A. Use a 25-gauge needle.
- B. Select a site on the client's abdomen.
- C. Use the Z-track technique to displace the skin on the injection site.
- D. Observe for bleb formation to confirm proper placement.
Correct Answer: B
Rationale: For subcutaneous injections like heparin, a 25-27 gauge needle is recommended, making choice A incorrect. The abdomen is a commonly used site for heparin injection due to its consistent absorption and convenience, making choice B the correct answer. The Z-track technique is not necessary for subcutaneous injections, making choice C unnecessary. Observing for bleb formation is not a standard practice for confirming proper placement of subcutaneous heparin, making choice D incorrect. Therefore, the correct action is to select a site on the client's abdomen for the injection.
The nurse is having difficulty reading the healthcare provider's written order that was written right before the shift change. What action should be taken?
- A. Leave the order for the oncoming staff to follow up
- B. Contact the charge nurse for an interpretation
- C. Ask the pharmacy for assistance in interpretation
- D. Call the provider for clarification
Correct Answer: D
Rationale: The nurse should call the provider for clarification. In situations where there is difficulty reading an order, it is crucial to directly contact the healthcare provider to ensure the correct order is understood and followed. Leaving the order for the oncoming staff (Choice A) may lead to misunderstandings and errors. Contacting the charge nurse (Choice B) may cause delays as they may also need to contact the provider. Asking the pharmacy (Choice C) is not the most direct and immediate action in this scenario, as the provider is the one who can provide immediate clarification.
An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the LPN/LVN implement first?
- A. Reaffirm the client's desire for no resuscitative efforts.
- B. Transfer the client to a hospice inpatient facility.
- C. Prepare the family for the client's impending death.
- D. Notify the healthcare provider of the family's request.
Correct Answer: D
Rationale: The first action the LPN/LVN should implement is to notify the healthcare provider of the family's request. This is crucial to ensure that appropriate steps are taken to address the family's request for hospice care and to coordinate the necessary care for the resident. While reaffirming the client's desire for no resuscitative efforts is important, notifying the healthcare provider takes precedence in this situation. Transferring the client to a hospice inpatient facility and preparing the family for the client's impending death are significant actions but should be done after notifying the healthcare provider to ensure proper coordination of care.
A client with a history of diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?
- A. Monitor the client's blood glucose level.
- B. Encourage the client to increase fluid intake.
- C. Administer insulin as prescribed.
- D. Assess the client's urine output.
Correct Answer: A
Rationale: The most important action for the LPN/LVN to take when a client with a history of diabetes mellitus experiences symptoms of hyperglycemia such as polyuria, polydipsia, and polyphagia is to monitor the client's blood glucose level. This action helps assess the severity of hyperglycemia and guides further interventions. Encouraging the client to increase fluid intake (Choice B) may exacerbate the symptoms by further diluting the blood glucose concentration. Administering insulin as prescribed (Choice C) should be done based on the healthcare provider's orders and after assessing the blood glucose levels. Assessing the client's urine output (Choice D) is important but not the most immediate action needed in this scenario.
While providing care to a group of patients, which patient should the nurse prioritize seeing first?
- A. A patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea
- B. A bedridden patient with a reddened area on the buttocks who needs to be turned
- C. A patient on bed rest with renal calculi who needs to go to the bathroom
- D. A patient post-knee surgery who needs range of motion exercises
Correct Answer: A
Rationale: The nurse should prioritize seeing the patient with a hip replacement on prolonged bed rest reporting chest pain and dyspnea first. This patient is at higher risk for deep vein thrombosis due to prolonged bed rest, which can lead to a life-threatening embolus. Chest pain and dyspnea could also indicate a potential pulmonary embolism, which requires immediate assessment and intervention. The other patients, while requiring care, do not present with symptoms that suggest an immediate life-threatening situation, making them lower priority at this time. Therefore, option A is the correct choice as it addresses a potentially critical condition that requires immediate attention.