Nokea
The practical nurse is assisting the registered nurse in preparing the room for a client with new-onset tonic-clonic seizures. It is important to ensure that what equipment is in the room? Select all that apply.
- A. Oral bite prevention device
- B. Oxygen delivery system
- C. Padding on the bed side rails
- D. Soft arm and leg restraints
- E. Suction equipment
Correct Answer: B,C,E
Rationale: Oxygen ensures adequate oxygenation during seizures, padding prevents injury from bed rails, and suction equipment clears airways if secretions accumulate. Oral bite devices are unsafe during seizures due to choking risks, and restraints are not typically used unless absolutely necessary.
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The nurse reinforces teaching for a client newly prescribed buspirone for generalized anxiety disorder. Which client statement indicates that teaching has been effective?
- A. Driving is not recommended until I stop taking this medication.
- B. If I experience a panic attack I should take an extra dose of medication.
- C. It will be 2-4 weeks before I feel the full effect of this medication.
- D. Withdrawal symptoms will occur if I abruptly stop taking this medication.
Correct Answer: C
Rationale: Buspirone takes 2-4 weeks for full effect, indicating effective teaching. Extra doses are unsafe, driving is generally allowed, and withdrawal is minimal.
The nurse has reinforced teaching with the parents of a 6-year-old client with chronic allergic rhinitis that is triggered by dust and pollen. Which of the following statements by the parents would indicate a correct understanding of the teaching? Select all that apply.
- A. We are planning to purchase an air purifier with a high-efficiency particulate air filter
- B. We will keep the windows open during warm weather to air out our house.
- C. We should place hypoallergenic covers on our child's mattress and pillow.
- D. We will clean our wood floors with a damp mop at least once a week
- E. We are planning to remove the carpet from our child's bedroom.
Correct Answer: A,C,D,E
Rationale: Correct choices reduce allergen exposure: HEPA filters remove dust/pollen, hypoallergenic covers prevent dust mite exposure, damp mopping reduces dust, and removing carpets eliminates allergen reservoirs. Keeping windows open increases pollen exposure, worsening symptoms.
The nurse is reinforcing teaching for the parents of a child newly diagnosed with hemophilia. Which long-term complication is important for the nurse to discuss?
- A. Heart valve injury
- B. Intellectual disability
- C. Joint destruction
- D. Recurrent pneumonia
Correct Answer: C
Rationale: Hemophilia causes recurrent joint bleeds, leading to joint destruction (hemophilic arthropathy), a key long-term complication.
The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube?
- A. Flush and aspirate the tube with warm water
- B. Instill a digestive enzyme solution into the tube
- C. Instill cola or cranberry juice into the tube
- D. Use a small barrel syringe to flush the tube
Correct Answer: A
Rationale: Flushing with warm water is the first, safest step to unclog a feeding tube. Enzymes or other solutions are used if water fails, and small syringes may cause excessive pressure.
There is a train wreck causing 46 casualties. The nurse is asking personnel on the floor to suggest clients who could be discharged to make room for casualties. Which client would be best for the LPN to suggest?
- A. A 77-year-old who had a fractured femur with hip replacement yesterday
- B. A 58-year-old who had an open cholecystectomy two days ago
- C. A 52-year-old who had a bowel resection with colostomy yesterday
- D. A 44-year-old who is undergoing internal radiation for cancer of the cervix
Correct Answer: B
Rationale: The client who had an open cholecystectomy two days ago is likely stable and closer to discharge compared to those with recent major surgeries or ongoing radiation, which require specialized care.