Nokea
A client is being treated for pneumonia and is receiving intravenous antibiotics. The nurse notes that the client has developed a rash and is complaining of itching. Which of the following is the most appropriate initial nursing action?
- A. Administer diphenhydramine (Benadryl)
- B. Discontinue the antibiotic infusion
- C. Apply a cool compress to the rash
- D. Notify the healthcare provider
Correct Answer: B
Rationale: The most appropriate initial nursing action when a client develops a rash and itching while receiving intravenous antibiotics is to discontinue the antibiotic infusion. This is crucial to prevent further allergic reactions. Administering diphenhydramine (Benadryl) (Choice A) can be considered after discontinuing the antibiotic infusion. Applying a cool compress to the rash (Choice C) may provide symptomatic relief but does not address the underlying cause. Notifying the healthcare provider (Choice D) is important but should come after discontinuing the antibiotic infusion to ensure the client's safety.
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The LPN/LVN is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?
- A. A college-age track runner with a sprained ankle.
- B. A lactating woman nursing her 3-day-old infant.
- C. A school-aged child with Type 2 diabetes.
- D. An elderly man being treated for a peptic ulcer.
Correct Answer: B
Rationale: The correct answer is B, a lactating woman nursing her 3-day-old infant. During lactation, women have increased nutritional needs, including protein, to support milk production for their infants. Protein is essential for proper growth and development. While choice A, a college-age track runner with a sprained ankle, may require protein for tissue repair, the lactating woman's need is greater due to the demands of breastfeeding. Choice C, a school-aged child with Type 2 diabetes, may have specific dietary considerations related to diabetes management but does not necessarily require additional protein intake compared to a lactating woman. Choice D, an elderly man being treated for a peptic ulcer, may need protein for wound healing, but the nutritional need for a lactating woman is higher to support her infant's growth.
The nurse is preparing to administer a subcutaneous injection of insulin to a client with diabetes. What is the best site for the nurse to select for this injection?
- A. Ventrogluteal site
- B. Dorsogluteal site
- C. Deltoid site
- D. Abdomen
Correct Answer: D
Rationale: The correct answer is 'D: Abdomen.' The abdomen is the best site for insulin injections as it provides a larger area with consistent absorption rates due to the high vascularity of the area. The subcutaneous tissue in the abdomen allows for a more predictable and consistent absorption of insulin compared to other sites. Ventrogluteal and dorsogluteal sites are not commonly used for insulin injections due to the risk of hitting the sciatic nerve or causing tissue damage. The deltoid site is more commonly used for intramuscular injections rather than subcutaneous injections like insulin.
When teaching the guardian of a 12-year-old male client about manifestations of puberty, which of the following physical changes typically occurs first?
- A. Appearance of downy hair on the upper lip
- B. Hair growth in the axillae
- C. Enlargement of the testes and scrotum
- D. Deepening of the voice
Correct Answer: C
Rationale: During puberty in males, the first physical change that typically occurs is the enlargement of the testes and scrotum. This change is due to increased production of testosterone, which stimulates growth and development of the genital organs. The appearance of downy hair on the upper lip (Choice A) and hair growth in the axillae (Choice B) usually follow the enlargement of the testes and scrotum. Deepening of the voice (Choice D) is a later stage change that occurs during puberty as the larynx (voice box) grows and the vocal cords lengthen and thicken.
The female is caring for a male patient who is uncircumcised but not ambulatory and has full function of all extremities. The nurse is providing the patient with a partial bed bath. How should perineal care be performed for this patient?
- A. Should be postponed because it may cause embarrassment.
- B. Should be unnecessary because the patient is uncircumcised.
- C. Should be done by the patient.
- D. Should be done by the nurse.
Correct Answer: C
Rationale: Perineal care should be encouraged to be done by the patient if they are capable of performing self-care. In this scenario, the patient is not ambulatory and has full function of all extremities, indicating that the patient can independently perform perineal care. Encouraging self-care promotes independence and maintains the patient's dignity. Postponing perineal care (Choice A) is incorrect because it is essential for hygiene. Choice B is incorrect as perineal care is necessary for all patients regardless of circumcision status. Choice D is incorrect as the patient is capable of performing the care independently, and promoting self-care is a priority in nursing practice.
A healthcare provider is delegating client care to assistive personnel. Which of the following tasks should the healthcare provider delegate?
- A. Evaluating healing of an incision
- B. Inserting an NG Tube
- C. Performing a simple dressing change
- D. Changing IV tubing
Correct Answer: C
Rationale: The correct task that a healthcare provider should delegate to assistive personnel is performing a simple dressing change. Assistive personnel are trained and competent in performing basic wound care activities like simple dressing changes. Evaluating the healing of an incision requires clinical judgment and assessment skills that are typically performed by licensed healthcare professionals, such as nurses or physicians. Inserting an NG tube and changing IV tubing involve invasive procedures that require specialized training and skills, making them tasks that should be performed by licensed healthcare providers rather than assistive personnel.