Nokea
A laboring woman says to the LPN/LVN, 'My baby is coming! My baby is coming!' She was last checked 15 minutes ago and was 5 cm dilated. What should the LPN/LVN do initially?
- A. Have her checked to see if she has progressed
- B. Reassure her that she cannot be that far along
- C. Reposition her to begin pushing
- D. Request medication to help her relax
Correct Answer: A
Rationale: Urgent reports of delivery sensation require immediate cervical check to confirm progression, as rapid labor can occur, ensuring timely intervention.
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An adult is being discharged from the emergency room with instructions to apply a cold pack to his sprained ankle. The client asks why it is necessary to use a cold pack. The nurse replies that the cold pack will do which of the following?
- A. Keep the sprain from becoming a fracture
- B. Prevent bruising and ecchymosis from occurring
- C. Keep the client from developing a fever
- D. Help reduce swelling and pain
Correct Answer: D
Rationale: Cold packs reduce swelling and pain by constricting blood vessels and numbing the area, aiding sprain recovery. They don't prevent fractures, bruising, or fever.
A client before administration of captopril (Capoten).
The MOST appropriate nursing action before administration of captopril (Capoten) would be to check the client's
- A. apical pulse for 60 seconds.
- B. blood pressure.
- C. urine output.
- D. temperature.
Correct Answer: B
Rationale: Strategy: Think about each answer choice and how it relates to Capoten. (1) important, but not a priority (2) correct-is an antihypertensive that necessitates that a BP be assessed prior to administration (3) important, but not priority (4) unnecessary to assess prior to the administration of the medication
A 12-year-old girl whose tracheostomy tube inserted 2 days ago has been accidentally dislodged.
The nurse should
- A. immediately replace the tracheostomy tube.
- B. suction the patient's airway using sterile technique.
- C. provide oxygen at 8 liters per minute per mask over the stoma.
- D. check for bilateral breath sounds immediately.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of the implementations. Remember ABCs. (1) correct-implementation, will secure the airway (2) implementation, will not provide for open airway (3) implementation, will not help with open airway (4) assessment, should be done after tracheostomy tube is replaced
The nurse is developing a comprehensive care plan for a young woman with an eating disorder. The nurse refers this client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with
- A. aggressive behaviors and angry feelings.
- B. self-identity and self-esteem.
- C. focusing on reality.
- D. family boundary intrusions.
Correct Answer: B
Rationale: clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do
A nursing assistant reports to the RN that a patient with anemia is complaining of weakness. Which of the following responses by the nurse to the nursing assistant is BEST?
- A. Listen to the patient's breath sounds and report back to me.'
- B. Set up the patient's lunch tray.'
- C. Obtain a diet history from the patient.'
- D. Instruct the patient to balance rest and activity.'
Correct Answer: B
Rationale: standard, unchanging procedure; decrease cardiac workload