Nokea
A client is admitted to the hospital in the terminal stage of cancer. The nurse enters the client's room to administer medications and finds the client crying. The appropriate nursing action is to:
- A. Sit and hold the client's hand
- B. Ask why the client is crying
- C. Leave the room to give the client privacy
- D. Administer the medications and leave
Correct Answer: A
Rationale: In end-of-life care, providing comfort and emotional support is essential. Sitting with the client, holding their hand, and offering a compassionate presence can help the client feel supported during a difficult time. Asking why the client is crying may not always be necessary as the focus should be on providing comfort rather than probing for information. Leaving the room to provide privacy or just administering medications and leaving may neglect the client's emotional needs and miss an opportunity to provide holistic care.
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A client has had their diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?
- A. smoothie
- B. sliced banana
- C. pancakes
- D. sunny side up (fried) eggs
Correct Answer: D
Rationale: The correct answer is 'D: sunny side up (fried) eggs.' Fried eggs should be removed as they are not suitable for a mechanical soft diet due to their texture. The yolk of a fried egg is usually too hard and can be difficult for a client on a mechanical soft diet to chew and swallow. Poached or scrambled eggs are better alternatives for this diet as they are softer and easier to consume. Choices A, B, and C are all suitable for a mechanical soft diet as they are softer in texture and easier to chew and swallow.
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the LPN/LVN implement first?
- A. Assist the ambulating client back to the bed.
- B. Encourage the client to ambulate to resolve pneumonia.
- C. Obtain a prescription for portable oxygen while ambulating.
- D. Move the oximetry probe from the finger to the earlobe.
Correct Answer: A
Rationale: The correct intervention is to assist the client back to bed. A decrease in oxygen saturation while ambulating indicates hypoxemia, and the immediate priority is to stabilize oxygen levels. Returning the client to bed allows for rest and decreased oxygen demand, potentially preventing further desaturation. Encouraging continued ambulation (Choice B) may worsen the hypoxemia by increasing oxygen demand. Obtaining portable oxygen (Choice C) is essential but should not delay addressing the low oxygen saturation. Moving the oximetry probe (Choice D) may not address the underlying cause of decreased oxygen saturation and should not be the first intervention.
When assessing readiness to learn about insulin self-administration, what indicates the client is ready to learn?
- A. I can concentrate best in the morning.
- B. I feel anxious about learning the process.
- C. I have a lot of questions about insulin.
- D. I am not sure if I can manage this at home.
Correct Answer: A
Rationale: The correct answer is A: 'I can concentrate best in the morning.' Readiness to learn is indicated by the client's ability to focus and concentrate, as mentioned in the question. Choice B, 'I feel anxious about learning the process,' indicates apprehension and may hinder the learning process. Choice C, 'I have a lot of questions about insulin,' shows interest but does not directly indicate readiness to learn. Choice D, 'I am not sure if I can manage this at home,' reflects uncertainty and lack of confidence, which may suggest the client is not fully prepared to learn.
The healthcare provider is preparing to administer a subcutaneous injection of heparin. Which site is most appropriate for the healthcare provider to use?
- A. Deltoid muscle
- B. Ventrogluteal site
- C. Abdomen
- D. Dorsogluteal site
Correct Answer: C
Rationale: The abdomen is the most appropriate site for administering subcutaneous heparin injections. The abdomen has a layer of subcutaneous fat and a good blood supply, making it an ideal site for subcutaneous injections. Using the deltoid muscle for heparin injections is not appropriate as it is typically used for intramuscular injections. The ventrogluteal site is more suitable for intramuscular injections rather than subcutaneous injections. The dorsogluteal site is no longer recommended for injections due to the risk of injury to the sciatic nerve.
A nurse on a medical-surgical unit has received change-of-shift report and will care for four clients. Which of the following tasks should the nurse assign to an assistive personnel (AP)?
- A. Updating the plan of care for a client who is postoperative
- B. Reinforcing teaching with a client who is learning to walk using a quad cane
- C. Reapplying a condom catheter for a client who has urinary incontinence
- D. Applying a sterile dressing to a pressure injury
Correct Answer: C
Rationale: The correct answer is C - 'Reapplying a condom catheter for a client who has urinary incontinence.' This task falls within the scope of duties for an assistive personnel (AP). Updating care plans (Choice A), reinforcing teaching (Choice B), and applying sterile dressings (Choice D) typically require a higher level of training and expertise, making them tasks that should not be assigned to an AP. Assigning appropriate tasks based on skill levels ensures safe and effective patient care.