Nokea
A healthcare professional is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the professional obtain to assess for this condition?
- A. Thermometer
- B. Elastic stockings
- C. Blood pressure cuff
- D. Sequential compression devices
Correct Answer: C
Rationale: To assess for orthostatic hypotension, a healthcare professional needs to obtain a blood pressure cuff. Orthostatic hypotension is defined as a drop in blood pressure greater than 20 mm Hg in systolic pressure or 10 mm Hg in diastolic pressure when moving from lying down to a standing position. A thermometer (Choice A) is used to measure body temperature and is not directly related to assessing orthostatic hypotension. Elastic stockings (Choice B) are used for preventing deep vein thrombosis and improving circulation in the lower extremities, not for assessing orthostatic hypotension. Sequential compression devices (Choice D) are mechanical pumps that are used to prevent deep vein thrombosis and are not specifically used for assessing orthostatic hypotension.
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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 client is being treated for pneumonia and is receiving intravenous antibiotics. The nurse notes that the client has developed a rash and is complaining of itching. Which of the following is the most appropriate initial nursing action?
- A. Administer diphenhydramine (Benadryl)
- B. Discontinue the antibiotic infusion
- C. Apply a cool compress to the rash
- D. Notify the healthcare provider
Correct Answer: B
Rationale: The most appropriate initial nursing action when a client develops a rash and itching while receiving intravenous antibiotics is to discontinue the antibiotic infusion. This is crucial to prevent further allergic reactions. Administering diphenhydramine (Benadryl) (Choice A) can be considered after discontinuing the antibiotic infusion. Applying a cool compress to the rash (Choice C) may provide symptomatic relief but does not address the underlying cause. Notifying the healthcare provider (Choice D) is important but should come after discontinuing the antibiotic infusion to ensure the client's safety.
A client has a closed wound drainage system. Which of the following actions should the nurse take?
- A. Avoid pressing the container down to create a vacuum
- B. Wear sterile gloves while handling the drainage system
- C. Reset the container with the drainage port closed
- D. Maintain the drain in a dependent position to facilitate drainage
Correct Answer: D
Rationale: In a closed wound drainage system, it is essential to maintain the drain in a dependent position to allow for proper drainage. Gravity aids in the flow of drainage, preventing fluid backflow or pooling. Avoiding pressing the container down to create a vacuum (Choice A) is crucial as it can lead to complications in the system. Wearing sterile gloves (Choice B) is important for infection control when handling the drainage system. Resetting the container with the drainage port closed (Choice C) is incorrect as it can cause spillage and contamination of the surrounding area.
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.
A client has recently started using a behind-the-ear hearing aid. Which of the following statements should the nurse identify as an indication that the client understands the use of this assistive device?
- A. This type of hearing aid allows for fine-tuning of volume.
- B. I should ensure the hearing aid stays secure during exercise.
- C. I might hear a whistling sound when I first insert the hearing aid.
- D. I will be sure to remove my hearing aid before taking a shower.
Correct Answer: D
Rationale: The correct answer is D because removing the hearing aid before taking a shower is essential to prevent water damage, as moisture can harm the device. Choice A is incorrect because behind-the-ear hearing aids do allow for fine-tuning of volume. Choice B is incorrect because exercise may cause the hearing aid to shift position, so it's important to ensure it stays secure. Choice C is incorrect because hearing a whistling sound when inserting the hearing aid may indicate improper placement or fit.