Nokea
A healthcare professional is preparing to administer medications to a client. Which of the following client identifiers should the healthcare professional use to ensure medication safety?
- A. Ask the client to state their full name.
- B. Ask the client for their date of birth.
- C. Compare the client's wristband with the medication administration record.
- D. Ask the client for their room number.
Correct Answer: C
Rationale: Comparing the client's wristband with the medication administration record is a crucial step in ensuring medication safety. The wristband typically contains unique identifiers such as the client's name, date of birth, and medical record number, which should be cross-checked with the medication administration record to confirm the correct patient. Asking the client to state their name (Choice A) or date of birth (Choice B) may not be as reliable as the information can be misunderstood or miscommunicated. Asking for the room number (Choice D) is not a reliable client identifier for medication administration and does not confirm the patient's identity accurately.
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A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor?
- A. Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back
- B. Pinch the skin on the back of the hand and observe for elasticity
- C. Assess the skin turgor on the abdomen by pinching the skin
- D. Check the skin turgor by pressing on the forearm and observing the rebound
Correct Answer: A
Rationale: To assess skin turgor, the nurse should grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back. This method is preferred for older adults and in cases of significant fluid imbalance. Option B is incorrect as assessing skin turgor on the back of the hand is not the standard assessment site for skin turgor. Option C is incorrect as the abdomen is not the typical area for assessing skin turgor; the chest under the clavicle is a more accurate site. Option D is incorrect as pressing on the forearm is not the appropriate site for evaluating skin turgor; the chest under the clavicle is the recommended location for this assessment.
A nurse educator is presenting a module on basic first aid for newly licensed home health nurses. The client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke is characterized by elevated body temperature, which can lead to hypotension (low blood pressure) due to dehydration and vasodilation. Bradycardia (slow heart rate) and clammy skin are not typical findings in heat stroke. Bradypnea (slow breathing) is also not a common feature of heat stroke. Therefore, hypotension is the most likely cardiovascular manifestation seen in a client with heat stroke.
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.
When admitting a 5-month-old who has vomited 9 times in the past 6 hours, what should the healthcare provider observe for signs of which overall imbalance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Increased serum hemoglobin levels
- D. Decreased serum potassium levels
Correct Answer: B
Rationale: When a 5-month-old infant vomits multiple times, there is a risk of developing metabolic alkalosis due to the loss of stomach acid. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels. It is caused by the loss of hydrogen ions from the body, often through vomiting. Metabolic acidosis (choice A) is unlikely in this scenario because it is more commonly associated with conditions like renal failure or diabetic ketoacidosis. Choice C, increased serum hemoglobin levels, is not typically a direct consequence of vomiting. Choice D, decreased serum potassium levels, may occur with vomiting but is not the primary concern when a patient is vomiting excessively.
A client with a history of chronic renal failure is admitted with generalized edema. Which laboratory value should the LPN/LVN monitor to assess the client's fluid balance?
- A. Serum potassium
- B. Serum calcium
- C. Serum albumin
- D. Serum sodium
Correct Answer: C
Rationale: The correct answer is C, Serum albumin. In clients with chronic renal failure and generalized edema, monitoring serum albumin levels is crucial as it is a key indicator of fluid balance. Low serum albumin levels can contribute to edema formation due to decreased oncotic pressure, indicating fluid imbalance. Serum potassium (Choice A) is more related to kidney function and electrolyte balance in renal failure patients. Serum calcium (Choice B) is important for bone health but is not directly related to fluid balance. Serum sodium (Choice D) is more indicative of hydration status and electrolyte balance but may not directly reflect fluid balance in the context of chronic renal failure and edema.