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A client with a terminal illness and approaching death has noisy respirations and is short of breath. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed
- B. Administer an opioid medication
- C. Perform oral suctioning
- D. Place the client in a prone position
Correct Answer: A
Rationale: Elevating the head of the client's bed is the most appropriate action in this situation. It helps reduce noisy respirations and improves comfort for clients with terminal illnesses by facilitating better air exchange. Administering an opioid medication may not address the immediate issue of noisy respirations and shortness of breath caused by secretions in the airway. Performing oral suctioning without proper assessment and indication can be uncomfortable for the client and may not be necessary. Placing the client in a prone position can further compromise breathing and is not recommended for a client with respiratory distress.
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If a security officer is reviewing actions to take in the event of a bomb threat by phone to a group of nurses, which statement by a nurse indicates understanding?
- A. "I will get the caller off the phone as soon as possible so I can alert the staff."
- B. "I will begin evacuating clients using the elevators."
- C. "I will not ask any questions and just let the caller talk."
- D. "I will listen for background noises."
Correct Answer: D
Rationale: The correct answer is D: "I will listen for background noises." Listening for background noises can provide useful information about the bomb's location, helping security to assess the situation more effectively. Choice A is incorrect because disconnecting the call abruptly may prevent gathering important details. Choice B is incorrect as using elevators during a bomb threat can be dangerous; it is safer to use stairs for evacuation. Choice C is incorrect because actively engaging with the caller to gather information is crucial in bomb threat situations.
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs?
- A. Autopsy of the body is prohibited.
- B. Blood transfusions are forbidden.
- C. Alcohol use in any form is not allowed.
- D. A vegetarian diet must be followed.
Correct Answer: B
Rationale: The correct answer is B: 'Blood transfusions are forbidden.' Jehovah's Witnesses typically refuse blood transfusions due to their religious beliefs. This is crucial for the LPN to consider when planning the client's care to ensure that alternative treatments are explored. Choices A, C, and D are incorrect as they do not align with the specific beliefs and practices of Jehovah's Witnesses. Autopsy prohibition, alcohol use restrictions, and dietary preferences are not primary concerns related to the religious beliefs of Jehovah's Witnesses.
The healthcare provider is caring for a client receiving chemotherapy. Which finding should the LPN/LVN report to the healthcare provider immediately?
- A. Mild nausea
- B. Hair loss
- C. Increased fatigue
- D. Fever of 101.5°F (38.6°C)
Correct Answer: D
Rationale: A fever of 101.5°F (38.6°C) in a client undergoing chemotherapy is a significant finding that may indicate an underlying infection, which can be life-threatening due to the client's compromised immune system. Prompt reporting and intervention are crucial to prevent complications. Mild nausea, hair loss, and increased fatigue are common side effects of chemotherapy and are expected findings that do not typically require immediate reporting unless they are severe or significantly impacting the client's well-being. Therefore, the LPN/LVN should prioritize reporting the fever over the other options.
A client with a new diagnosis of diabetes mellitus is being taught how to administer insulin. Which of the following instructions should the nurse include?
- A. Administer the insulin in the same body area each time.
- B. Store the insulin according to the manufacturer's instructions.
- C. Rotate injection sites within the same body area.
- D. Inject the insulin at a 45-degree angle.
Correct Answer: C
Rationale: The correct instruction the nurse should include is to rotate injection sites within the same body area. This practice helps prevent lipodystrophy, a condition characterized by the thickening or thinning of subcutaneous fat at the injection sites, which can affect insulin absorption. Choice A is incorrect because administering insulin in the same area each time can lead to lipodystrophy. Choice B is incorrect as insulin should be stored according to the manufacturer's instructions, which may include refrigeration. Choice D is incorrect because the angle of insulin injection (usually 90 degrees) is determined by the length of the needle and the amount of subcutaneous fat, not a fixed 45-degree angle.
How should the nurse transcribe the dosage of this medication on the client's medical record?
- A. 0.3 mg
- B. 0.3 mg
- C. 0.30 mg
- D. 3/10 mg
Correct Answer: B
Rationale: The correct way to transcribe the dosage of three tenths of a milligram of levothyroxine IV STAT is 0.3 mg. When expressing decimals less than 1, there should be a leading zero before the decimal point. Choice A is incorrect (.3 mg) because it lacks the leading zero. Choice C (0.30 mg) is incorrect as it includes a trailing zero after the decimal point, which is unnecessary. Choice D (3/10 mg) is incorrect as it presents the dosage as a fraction, which is not the standard format for transcribing medication dosages. Therefore, B (0.3 mg) is the most appropriate and accurate way to document this prescription on the client's medical record.