Nokea
A healthcare provider is providing teaching to a client who has a new medication prescription. Which of the following manifestations of a mild allergic reaction should the healthcare provider include?
- A. Ptosis
- B. Hematuria
- C. Urticaria
- D. Nausea
Correct Answer: C
Rationale: Urticaria, also known as hives, is a common manifestation of a mild allergic reaction. Ptosis refers to drooping of the eyelid and is not typically associated with allergic reactions. Hematuria indicates blood in the urine and is not a typical allergic reaction symptom. Nausea can occur with various conditions, but it is not a specific manifestation of a mild allergic reaction.
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What intervention should be implemented by the LPN to reduce the risk of aspiration in a client with a nasogastric tube receiving continuous enteral feedings?
- A. Elevate the head of the bed to 30-45 degrees.
- B. Check residual volumes every 4 hours.
- C. Verify tube placement every shift.
- D. Flush the tube with water every 4 hours.
Correct Answer: A
Rationale: Elevating the head of the bed to 30-45 degrees is crucial in reducing the risk of aspiration because it helps keep the gastric contents lower than the esophagus, thereby promoting proper digestion and preventing reflux. This position also aids in reducing the likelihood of regurgitation and aspiration of gastric contents. Checking residual volumes every 4 hours is important for monitoring feeding tolerance but does not directly address the risk of aspiration. Verifying tube placement every shift is essential for ensuring the tube is correctly positioned within the gastrointestinal tract but does not directly reduce the risk of aspiration. Flushing the tube with water every 4 hours may help maintain tube patency and prevent clogging, but it does not specifically address the risk of aspiration associated with nasogastric tube feedings.
The healthcare provider is assessing a client with suspected tuberculosis. Which symptom would be most concerning?
- A. Night sweats
- B. Weight loss
- C. Cough with bloody sputum
- D. Fatigue
Correct Answer: C
Rationale: Cough with bloody sputum is a hallmark symptom of tuberculosis and is highly concerning as it indicates active disease. Hemoptysis (coughing up blood) is associated with tuberculosis infection in the lungs. While night sweats and weight loss are common symptoms of tuberculosis, they are less specific than coughing with bloody sputum. Fatigue is a nonspecific symptom that can be present in various conditions and is not specific to tuberculosis.
An older adult client at risk for osteoporosis is being taught by a nurse about starting a regular physical activity program. Which type of activity should the nurse recommend?
- A. Walking briskly
- B. Riding a bicycle
- C. Performing isometric exercises
- D. Engaging in high-impact aerobics
Correct Answer: A
Rationale: The correct answer is walking briskly. Weight-bearing exercises, such as brisk walking, are recommended for individuals at risk for osteoporosis because they help maintain bone mass and prevent bone loss. Riding a bicycle and performing isometric exercises are not weight-bearing activities, and therefore, may not provide the same bone-strengthening benefits as walking. High-impact aerobics can increase the risk of fractures in individuals with osteoporosis due to the high level of impact involved.
When should discharge planning for a patient admitted to the neurological unit with a diagnosis of stroke begin?
- A. At the time of admission
- B. The day before the patient is to be discharged
- C. When outpatient therapy is no longer needed
- D. As soon as the patient's discharge destination is known
Correct Answer: A
Rationale: Discharge planning for a patient admitted to the neurological unit with a stroke diagnosis should begin at the time of admission. Initiating discharge planning early allows for a comprehensive assessment of the patient's needs, enables better coordination of care, and ensures a smooth transition from the hospital to the next level of care. Option B is incorrect because waiting until the day before discharge does not provide enough time for adequate planning. Option C is incorrect because waiting until outpatient therapy is no longer needed delays the planning process. Option D is incorrect because waiting until the discharge destination is known may result in rushed planning and inadequate preparation for the patient's needs.
A healthcare professional is instructing an AP about caring for a client who has a low platelet count. Which of the following instructions is the priority for measuring vital signs for this client?
- A. Avoid measuring the client's temperature rectally.
- B. Count the client's radial pulse for 30 seconds and multiply it by 2.
- C. Count the client's respirations discreetly.
- D. Allow the client to rest for 5 minutes before measuring their BP.
Correct Answer: A
Rationale: The correct answer is to avoid measuring the client's temperature rectally. Rectal temperatures can cause bleeding in clients with low platelet counts. It is crucial to avoid invasive methods that could increase the risk of bleeding or discomfort. Choice B, counting the radial pulse, is not directly related to the risk of bleeding in a client with low platelet count. Choice C, counting respirations discreetly, is important for accuracy but is not the priority when considering the risk of bleeding. Choice D, letting the client rest before measuring blood pressure, is beneficial but is not the priority in preventing potential harm due to low platelet counts.