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A client diagnosed with a terminal illness asks the nurse about the nurse's religious beliefs related to death and dying. An appropriate nursing response is to:
- A. Share personal beliefs
- B. Encourage the client to express their thoughts about death and dying
- C. Redirect the conversation to medical treatment
- D. Inform the client that the nurse's beliefs are not relevant
Correct Answer: B
Rationale: Encouraging the client to express their own thoughts about death and dying is an appropriate nursing response in this situation. It allows the client to explore and express their feelings, fears, and beliefs, facilitating a therapeutic conversation. Sharing personal beliefs (choice A) may not be appropriate as it could impose the nurse's beliefs on the client and hinder open discussion. Redirecting the conversation to medical treatment (choice C) may avoid addressing the client's emotional and spiritual needs. Informing the client that the nurse's beliefs are not relevant (choice D) dismisses the client's concerns and does not encourage open communication.
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A nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take?
- A. Administer the medication with the needle at a 45-degree angle.
- B. Administer the medication with the needle at a 90-degree angle.
- C. Administer the medication with the needle at a 30-degree angle.
- D. Administer the medication with the needle at a 15-degree angle.
Correct Answer: B
Rationale: Enoxaparin should be administered with the needle at a 90-degree angle to ensure proper subcutaneous delivery. Choice B is correct as it aligns with the recommended angle for subcutaneous injections. Administering enoxaparin at a 45-degree angle (Choice A), 30-degree angle (Choice C), or 15-degree angle (Choice D) would not be appropriate and may lead to improper administration or absorption of the medication.
When assisting an 82-year-old client to ambulate, it is important for the LPN/LVN to realize that the center of gravity for an elderly person is in the
- A. Arms.
- B. Upper torso.
- C. Head.
- D. Feet.
Correct Answer: B
Rationale: The correct answer is 'Upper torso.' In elderly individuals, the center of gravity tends to shift upwards towards the upper torso due to various factors such as changes in posture and muscle strength. Understanding this is crucial for safe ambulation as it helps in maintaining balance and stability. Choices A, 'Arms,' C, 'Head,' and D, 'Feet,' are incorrect. The center of gravity is not typically located in the arms, head, or feet. It is higher up in the body, specifically in the upper torso. Knowing the correct location of the center of gravity is essential for assisting elderly clients in ambulation effectively and preventing falls.
A client receives the influenza vaccine in a clinic. Within 15 minutes after the immunization, the client complains of itchy and watery eyes, increased anxiety, and difficulty breathing. What should be the first action in the sequence of care for this client?
- A. Maintain the airway
- B. Administer epinephrine 1:1000 as ordered
- C. Monitor for hypotension with shock
- D. Administer diphenhydramine as ordered
Correct Answer: B
Rationale: In the scenario described, the client is experiencing symptoms of an anaphylactic reaction, a severe allergic response. The priority action in an anaphylactic reaction is to administer epinephrine. Epinephrine helps counteract the severe allergic response, improves breathing difficulties, and maintains airway and circulation. Administering epinephrine takes precedence to stabilize the client's condition. Options A, C, and D may be necessary in the management of anaphylaxis, but the immediate priority is to administer epinephrine to address the life-threatening symptoms.
The client is being discharged and has been prescribed furosemide (Lasix). Which statement by the client indicates an understanding of the medication?
- A. I will take this medication on an empty stomach for optimal absorption.
- B. I will weigh myself daily and report any significant weight loss.
- C. I will include potassium-rich foods in my diet while taking this medication.
- D. I will take this medication in the morning to prevent nocturia.
Correct Answer: B
Rationale: The correct answer is B. Weighing daily and reporting significant weight loss is crucial when taking furosemide to monitor for potential fluid and electrolyte imbalances. Choice A is incorrect because furosemide is typically taken on an empty stomach for optimal absorption. Choice C is incorrect as furosemide can lead to potassium loss, so potassium-rich foods should be consumed. Choice D is incorrect because furosemide is usually taken earlier in the day to prevent nocturia, not at bedtime.
The healthcare professional is preparing to administer an intramuscular injection to an adult client. Which site is most appropriate for the LPN/LVN to use?
- A. Deltoid muscle
- B. Ventrogluteal site
- C. Dorsogluteal site
- D. Rectus femoris site
Correct Answer: B
Rationale: The ventrogluteal site is the most appropriate and safest site for administering an intramuscular injection to an adult client. It is preferred due to its thick muscle mass and fewer major blood vessels and nerves in the area, reducing the risk of injury or complications. The deltoid muscle is commonly used for vaccines and small-volume injections but may not be suitable for larger volumes. The dorsogluteal site has fallen out of favor due to the risk of injury to the sciatic nerve and other underlying structures. The rectus femoris site is not typically used for intramuscular injections in adults.