Nokea
A 2-month-old recently diagnosed with developmental dysplasia of the hip is beginning treatment with a Pavlik harness. Which instructions should the nurse reinforce to the parents? Select all that apply.
- A. Apply lotion under the straps to protect the skin.
- B. Dress the child in a shirt and knee socks under the straps.
- C. Lightly massage the skin under the straps daily.
- D. Place the diaper under the straps.
- E. Remove the harness during diaper changes.
Correct Answer: B,C,D
Rationale: Shirts and socks under straps prevent chafing, daily massage promotes circulation, and diapers under straps ensure hygiene. Lotion traps moisture, risking irritation. The harness should not be removed, even for diaper changes, to maintain correction.
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The nurse is talking with the spouse of a client who is eligible for hospice care. The spouse states, 'I do not know if I can make this decision. What would you do?' Which of the following responses would be appropriate for the nurse to make?
- A. These decisions are challenging. Tell me about your spouse's beliefs regarding end-of-life care.
- B. You seem overwhelmed. I will ask the chaplain to speak with you about available options.
- C. I find it helpful to investigate all options. I will get you a pamphlet about hospice services.
- D. I had to make a similar decision when my spouse was ill. Do what feels best for you.
Correct Answer: A
Rationale: The nurse should remain neutral and facilitate discussion about the client's values and preferences, helping the spouse make an informed decision without personal bias or directing to other resources prematurely.
The licensed practical nurse is working with a registered nurse to care for a client who has just returned to the cardiac unit after having a percutaneous coronary intervention. Which actions assigned by the registered nurse should the practical nurse question as outside of the practical nurse's scope of practice? Select all that apply.
- A. Administering oral pain medication if client reports low back pain
- B. Checking for bleeding at the catheter insertion site every 15 minutes
- C. Performing post-procedure vital sign measurements
- D. Reinforcing instructions to keep the involved extremity straight
- E. Reviewing ECG for dysrhythmias
Correct Answer: E
Rationale: Reviewing ECGs for dysrhythmias requires advanced assessment skills beyond LPN scope. Administering medication, checking for bleeding, taking vital signs, and reinforcing instructions are within LPN scope if trained.
The nurse is caring for a client with latent pulmonary tuberculosis who has been receiving isoniazid daily for the past 2 months. The client reports numbness and tingling in the hands and feet. The nurse should recognize that the client is likely experiencing a deficiency in
- A. iron
- B. vitamin B6
- C. folic acid
- D. vitamin D3
Correct Answer: B
Rationale: Isoniazid can deplete vitamin B6 (pyridoxine), causing peripheral neuropathy (numbness, tingling). Other deficiencies (iron, folic acid, vitamin D3) don't typically cause neuropathy.
The nurse is monitoring a client who is going through barbiturate withdrawal. Which symptom is of most concern to the nurse?
- A. Nausea and vomiting
- B. Anxiety
- C. Hallucinations
- D. Seizures
Correct Answer: D
Rationale: Seizures in barbiturate withdrawal are life-threatening, requiring immediate intervention, unlike nausea, anxiety, or hallucinations.
After assisting a client with a lower gastrointestinal bleed back to bed, the nurse finds approximately 600 mL of frank red blood in the toilet. The client is pale and diaphoretic and reports dizziness. Which action should the nurse perform first?
- A. Document the output and vital signs
- B. Draw blood for hemoglobin and hematocrit
- C. Lower the head of the bed
- D. Notify the registered nurse
Correct Answer: C
Rationale: Significant bleeding (600 mL), pallor, diaphoresis, and dizziness suggest hypovolemia. Lowering the head of the bed improves cerebral perfusion, stabilizing the client. Notification, labs, and documentation follow stabilization.