Nokea
A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by:
- A. pleurisy.
- B. pleural effusion.
- C. atelectasis.
- D. tuberculosis.
Correct Answer: A
Rationale: Pleurisy is an inflammation of the pleura and is often accompanied by abrupt onset of pain. Symptoms of pleurisy are abrupt pain that is usually unilateral and localized to a specific portion of the chest.
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Which of the following tasks can the practical nurse (PN) safely assign to an experienced unlicensed assistive personnel (UAP)? Select all that apply.
- A. Ambulate an oxygen-dependent client to the bathroom
- B. Check pulse oximetry for a client with respiratory rate 12/min
- C. Instruct a client with pneumonia on usage of the incentive spirometer
- D. Provide oral hygiene to a client with chronic obstructive pulmonary disease (COPD)
- E. Turn and reposition a client with pneumonia
Correct Answer: A,B,D,E
Rationale: UAP can ambulate stable clients , check pulse oximetry , provide oral hygiene , and reposition clients . Instructing on incentive spirometry requires nursing judgment and is not delegable.
The nurse understands that a priority goal of involuntary hospitalization of the severely mentally ill client is
- A. Re-orientation to reality
- B. Elimination of symptoms
- C. Protection from harm to self or others
- D. Return to independent functioning
Correct Answer: C
Rationale: Protection from harm to self or others. Involuntary hospitalization is required for individuals who are dangerous to themselves or others.
The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?
- A. Fluid restriction 1000cc per day
- B. Ambulate in hallway 4 times a day
- C. Administer analgesic therapy as ordered
- D. Encourage increased caloric intake
Correct Answer: C
Rationale: Administer analgesic therapy as ordered. Pain management is critical during a sickle cell crisis.
An adult male has an IV in the left arm. The client calls the nurse and says that his left arm hurts. The LPN checks the IV site and notes that it is cool and blanched and not running well. What should the LPN do at this time?
- A. Flush the IV with normal saline
- B. Remove the IV immediately and start a new line
- C. Tell the charge nurse that the client's IV appears to be infiltrated
- D. Ask the charge nurse to check to see if the client has phlebitis
Correct Answer: B
Rationale: Cool, blanched skin and poor flow indicate infiltration; removing the IV and starting a new line prevents tissue damage.
The nurse in a clinic is caring for an 8-month-old client with a new diagnosis of bronchiolitis due to respiratory syncytial virus. Which of the following instructions should the nurse provide to the parent?
- A. Administration of a cough suppressant and an antihistamine
- B. Prophylactic treatment of family members
- C. Temporary cessation of breastfeeding
- D. Use of saline drops and a bulb syringe to suction nares
Correct Answer: D
Rationale: For bronchiolitis due to RSV, saline drops and bulb syringe suctioning help clear nasal passages, improving breathing. Cough suppressants and antihistamines are not recommended as they may suppress necessary cough or cause sedation. Prophylactic treatment is not standard for family members unless immunocompromised, and breastfeeding should continue to provide antibodies.