Nokea
A client with a history of coronary artery disease is experiencing chest pain. What is the priority action for the LPN/LVN to take?
- A. Administer nitroglycerin sublingually.
- B. Obtain a 12-lead ECG.
- C. Measure the client's vital signs.
- D. Administer oxygen via nasal cannula.
Correct Answer: A
Rationale: The correct answer is to administer nitroglycerin sublingually. Administering nitroglycerin sublingually is the priority action for a client with chest pain and a history of coronary artery disease. Nitroglycerin helps dilate the coronary arteries, improving blood flow to the heart muscle and providing rapid relief of chest pain. Obtaining a 12-lead ECG, measuring vital signs, and administering oxygen are important actions but should follow the administration of nitroglycerin in the management of chest pain in a client with coronary artery disease.
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A 2-year-old child is brought to the health care provider's office with a chief complaint of mild diarrhea for 2 days. Nutritional counseling by the nurse should include which statement?
- A. Place the child on clear liquids and gelatin for 24 hours
- B. Continue with the regular diet and include oral rehydration fluids
- C. Give bananas, apples, rice, and toast as tolerated
- D. Place NPO for 24 hours, then rehydrate with milk and water
Correct Answer: B
Rationale: In managing mild diarrhea in a 2-year-old child, it is important to maintain their regular diet and include oral rehydration fluids. Choice A of placing the child on clear liquids and gelatin for 24 hours may not provide adequate nutrition and can lead to further electrolyte imbalances. Choice C of giving bananas, apples, rice, and toast as tolerated is a part of the BRAT diet, which is not recommended as the primary approach anymore due to its limited nutritional value. Choice D of placing the child NPO for 24 hours and then rehydrating with milk and water is not appropriate as it can worsen dehydration and delay recovery. Therefore, the best option is to continue the child's regular diet while incorporating oral rehydration fluids to prevent dehydration and maintain nutritional status.
A client is admitted to a voluntary hospital mental health unit due to suicidal ideation. The client has been on the unit for 2 days and now states, 'I demand to be released now!' The appropriate action is for the nurse to:
- A. You cannot be released because you are still suicidal.
- B. You can be released only if you sign a no-suicide contract.
- C. Let's discuss your decision to leave and then we can prepare you for discharge.
- D. You have a right to sign out as soon as we get an order from the healthcare provider's discharge order.
Correct Answer: C
Rationale: The correct action for the nurse in this scenario is to engage the client in a discussion about their decision to leave and then prepare them for discharge. This approach allows the nurse to assess the client's current state, address concerns, and plan for a safe discharge. Option A is incorrect because it does not involve a therapeutic communication approach and may escalate the situation. Option B is incorrect as it places a condition on the client for release, which is not recommended in this situation. Option D is incorrect as it does not prioritize the client's autonomy and right to make decisions about their care.
A nurse questions a medication prescription as too extreme in light of the client's advanced age and unstable status. The nurse understands that this action is an example of which of the following ethical principles?
- A. Fidelity
- B. Autonomy
- C. Justice
- D. Nonmaleficence
Correct Answer: D
Rationale: The correct answer is D, Nonmaleficence. Nonmaleficence refers to the principle of 'do no harm.' In this scenario, questioning a potentially harmful prescription for a client with advanced age and unstable status aligns with the principle of nonmaleficence, as the nurse is advocating for the client's safety and well-being. Choice A, Fidelity, refers to being faithful and keeping promises, which is not directly related to the situation described. Choice B, Autonomy, pertains to respecting a patient's right to make their own decisions, which is not the focus of the nurse questioning the prescription. Choice C, Justice, involves fairness and equal treatment, which is not the primary ethical principle at play in this situation.
A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
- A. Clean sutures along the incision site.
- B. Grasp the knot of the sutures with forceps.
- C. Cut the sutures close to the skin on one side.
- D. Pull out the sutures with forceps in one piece.
Correct Answer: A
Rationale: The correct action for the nurse to take next after preparing the suture remover kit and applying sterile gloves is to clean sutures along the incision site. This step is crucial in preventing infection, which is the greatest risk to the client during suture removal. Cleaning the site helps minimize the risk of introducing microorganisms into the incision, reducing the chances of infection. Grasping at the knot of the sutures with forceps (Choice B) is incorrect as it does not address the need to clean the incision. Cutting the sutures close to the skin on one side (Choice C) or pulling out the sutures with forceps in one piece (Choice D) without proper cleaning can increase the risk of infection and should not be the next step in the process of suture removal.
The healthcare provider is planning care for a 14-year-old client returning from scoliosis corrective surgery. Which of the following actions should receive priority in the plan?
- A. Administer antibiotic therapy for 10 days
- B. Teach the client isometric exercises for legs
- C. Assess movement and sensation of extremities
- D. Assist the client to stand up at the bedside within the first 24 hours
Correct Answer: C
Rationale: Assessing movement and sensation of extremities is the priority after scoliosis corrective surgery as it helps in early detection of any neurological deficits that may have occurred during the procedure. This assessment is essential for prompt intervention if any issues are identified. Administering antibiotics, teaching exercises, and assisting the client to stand up are important aspects of care but assessing neurological status takes precedence to ensure the client's safety and recovery.