Nokea
A client is immobile due to a cast, and a nurse is assisting in the use of a fracture bedpan. Which of the following actions should the nurse take?
- A. Place the shallow end of the fracture pan under the client's buttocks.
- B. Encourage the client to remain immobile on the fracture pan for 20 minutes.
- C. Keep the bed flat while the client is on the fracture pan.
- D. Hyperextend the client's back while the fracture pan is in place.
Correct Answer: A
Rationale: The correct action when using a fracture bedpan for an immobile client is to place the shallow end of the pan under the client's buttocks. This positioning helps in proper collection of feces without causing discomfort or injury. Encouraging the client to try to defecate for 20 minutes (Choice B) is inappropriate and unrealistic, as defecation should not be forced or timed. Keeping the bed flat (Choice C) is incorrect as elevating the head of the bed can help promote proper positioning for bedpan use. Hyperextending the client's back (Choice D) is contraindicated and can lead to discomfort and potential injury to the client.
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A client with a history of severe anxiety is scheduled for surgery. Which preoperative medication is the most appropriate for the LPN/LVN to administer to this client?
- A. Lorazepam (Ativan)
- B. Morphine sulfate
- C. Meperidine (Demerol)
- D. Promethazine (Phenergan)
Correct Answer: A
Rationale: Lorazepam (Ativan) is the most appropriate preoperative medication for a client with severe anxiety. Lorazepam belongs to the benzodiazepine class and is commonly used to manage anxiety before surgical procedures due to its anxiolytic properties. Morphine sulfate and Meperidine (Demerol) are opioid analgesics, not typically indicated for preoperative anxiety. Promethazine (Phenergan) is an antihistamine used for nausea and vomiting, not anxiety management.
A healthcare professional is admitting a client who has influenza. Which of the following types of transmission precautions should the healthcare professional initiate?
- A. Airborne
- B. Droplet
- C. Contact
- D. Protective environment
Correct Answer: B
Rationale: Droplet precautions should be initiated for clients with infections that spread via droplet nuclei larger than 5 microns in diameter, such as influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. In the case of influenza, the virus is primarily spread through respiratory droplets produced when an infected person coughs, sneezes, or talks. Airborne precautions are used for pathogens that remain infectious over long distances, typically smaller than 5 microns, like tuberculosis. Contact precautions are for diseases transmitted by direct or indirect contact, and protective environment precautions are for immunocompromised individuals to protect them from environmental pathogens.
The pediatric clinic nurse examines a toddler with a tentative diagnosis of neuroblastoma. Findings observed by the nurse that are associated with this problem include which of these?
- A. Lymphedema and nerve palsy
- B. Hearing loss and ataxia
- C. Headaches and vomiting
- D. Abdominal mass and weakness
Correct Answer: D
Rationale: The correct answer is D: Abdominal mass and weakness. In neuroblastoma, the most common presenting signs are related to the mass effect of the tumor, leading to an abdominal mass and symptoms of weakness. Lymphedema and nerve palsy (Choice A) are not typically associated with neuroblastoma. Hearing loss and ataxia (Choice B) are more indicative of other conditions like neurofibromatosis or brain tumors. Headaches and vomiting (Choice C) are more commonly seen in conditions such as brain tumors or increased intracranial pressure, but they are not specific to neuroblastoma.
A client with a diagnosis of hypertension is being assessed. Which symptom would be most concerning?
- A. Headache
- B. Blurred vision
- C. Dizziness
- D. Chest pain
Correct Answer: D
Rationale: Chest pain in a client with hypertension is the most concerning symptom as it may indicate a myocardial infarction or other serious cardiac event related to hypertension. Immediate intervention is required to address potential life-threatening conditions. Headache, blurred vision, and dizziness are common symptoms associated with hypertension but are not typically indicative of an acute cardiac event requiring urgent attention.
A healthcare professional is providing care to a client who has a tracheostomy. Which of the following actions should the professional take to prevent complications?
- A. Clean around the stoma with povidone-iodine.
- B. Maintain sterile technique when performing tracheostomy care.
- C. Use clean technique when suctioning the tracheostomy.
- D. Change tracheostomy ties weekly.
Correct Answer: B
Rationale: Maintaining sterile technique when performing tracheostomy care is essential in preventing infections and complications. Option A is incorrect because povidone-iodine may be too harsh for cleaning around the stoma and can lead to skin irritation. Option C is incorrect because suctioning a tracheostomy should be done using sterile technique to minimize the risk of introducing pathogens. Option D is incorrect as tracheostomy ties need to be changed more frequently, usually every 1-2 days, to prevent skin breakdown and infection.