Nokea
A client arrives in the emergency room with severe burns of the hands, right arm, face, and neck. The nurse needs to start an IV. Which site would be most suitable for this client?
- A. Top of client's right hand
- B. Left antecubital fossa
- C. Top of either foot
- D. Left forearm
Correct Answer: B
Rationale: The left antecubital fossa is suitable as it is away from burned areas (hands, right arm, face, neck) and provides a large vein for IV access.
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When examining an 80-year-old client with chronic COPD receiving home health care, the nurse notes that over the previous 48 hours the client has developed scattered painful pustular lesions on the right arm near the elbow (see photo), on the back of the neck, the face, and on both legs. Which of the following does the nurse suspect is the most likely cause of the lesions?
- A. Psoriasis
- B. Herpes zoster
- C. MRSA
- D. Contact dermatitis
Correct Answer: C
Rationale: Painful pustular lesions in a client with chronic illness suggest MRSA (C), a common healthcare-associated infection. Psoriasis (A) presents with scaly plaques, herpes zoster (B) follows a dermatomal pattern, and contact dermatitis (D) is typically itchy, not pustular.
The nurse is caring for a client in the clinic who takes captopril and ramipril for hypertension. The health care provider renews the client's prescriptions and leaves the room. Which comment by the client would prompt the nurse to notify the health care provider immediately?
- A. I am able to start walking longer at the gym without getting tired.
- B. Occasionally I am slightly dizzy when standing, so I get up slowly.
- C. I don't get short of breath anymore now that my blood pressure is controlled.
- D. I am going to my gynecologist tomorrow for my 12-week pregnancy checkup.
Correct Answer: D
Rationale: Captopril and ramipril (ACE inhibitors) are contraindicated in pregnancy due to fetal harm, requiring immediate provider notification.
The rationale for inserting a French catheter every hour for the client with epidural anesthesia is:
- A. The bladder fills more rapidly because of the medication used for the epidural.
- B. Her level of consciousness is such that she is in a trancelike state.
- C. The sensation of the bladder filling is diminished or lost.
- D. She is embarrassed to ask for the bedpan that frequently.
Correct Answer: C
Rationale: Epidural anesthesia can reduce bladder sensation, necessitating frequent catheterization to prevent overdistension.
In caring for a critically ill client with a nasogastric tube (NGT) for enteral feeding, which action by the nurse demonstrates competency in NGT care? Select all that apply.
- A. The nurse checks gastric residual every 4 hours for continuous feedings.
- B. The nurse maintains the client in a low Fowler's position during feeding.
- C. The nurse checks gastric residual before each bolus or intermittent feeding.
- D. The tubing is changed every 48 hours or when the bag appears visibly soiled.
- E. The nurse returns the residual to the stomach unless the volume is greater than 250 mL.
Correct Answer: A, C, E
Rationale: Checking residuals for continuous and bolus feedings and returning residuals (unless >250 mL) are standard. Low Fowler’s increases aspiration risk, and tubing change frequency varies by policy.
The nurse is caring for a client on the oncology unit. Which nursing activity is appropriate to delegate to the unit LPN?
- A. obtaining vital signs
- B. administering blood
- C. administering IV pain medication
- D. administering chemotherapy if the nurse is busy with another client
Correct Answer: A
Rationale: Obtaining vital signs is within the LPN’s scope. Administering blood, IV pain medication, or chemotherapy typically requires RN expertise.