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A nurse finds a client unresponsive and is unable to palpate a pulse. Resuscitation is initiated and continued by the rapid response team. The nurse then finds a do not resuscitate (DNR) prescription in the client's chart. What is the appropriate action by the nurse?
- A. Complete resuscitation as life support measures have already been started
- B. Continue resuscitation until DNR status is verified with health care provider
- C. Immediately have the rapid response team stop resuscitation measures
- D. Verify with a family member if life-saving measures should be continued
Correct Answer: C
Rationale: A DNR order indicates the client's wish to avoid resuscitation. Once discovered, resuscitation should be stopped immediately to respect the client's directive, unless there is clear evidence the order is invalid.
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A client is receiving nitroprusside IV for the treatment of acute heart failure with pulmonary edema. What diagnostic lab value should the nurse monitor when a client is receiving this medication?
- A. Potassium level
- B. Arterial blood gasses
- C. Blood urea nitrogen
- D. Thiocyanate
Correct Answer: D
Rationale: Thiocyanate. Nitroprusside metabolism increases thiocyanate levels, which can lead to cyanide toxicity if elevated.
The physician has ordered O2 at 3 liters/minute for a client with emphysema. Which device will deliver the most precise level of oxygen prescribed for the client?
- A. Nasal cannula
- B. Partial rebreather mask
- C. Simple face mask
- D. Venturi mask
Correct Answer: D
Rationale: The Venturi mask will deliver the most precise level of oxygen for the client with COPD. Answer A is incorrect, because the client may lose oxygen through an open mouth. Answers B and C are incorrect, because they are not used to deliver oxygen to the client with COPD.
The nurse is preparing to assist a client to ambulate to the bathroom. The client rises from the chair at the bedside and immediately reports feeling dizzy. It would be a priority for the nurse to
- A. Check the client's orthostatic blood pressure
- B. encourage the client to remain on bed rest
- C. apply a gait belt around the client's waist
- D. assist the client back to a sitting position
Correct Answer: D
Rationale: Dizziness upon standing suggests orthostatic hypotension or other instability. Assisting the client back to a sitting position prevents falls and ensures immediate safety.
A client undergoes cryosurgery for the removal of a basal cell carcinoma on the ear. Which of the following best describes the appearance of the area a few days after surgery?
- A. It's dry, crusty, and itchy.
- B. It's oozing and painful.
- C. It's dry and tender.
- D. It's swollen, tender, and blistered.
Correct Answer: A
Rationale: Post-cryosurgery, the treated area typically forms a dry, crusty scab and may be itchy as it heals.
The mother of a 4-month-old infant calls the physician's office reporting that her child has a temperature of 101°F and a rash that is blanchable and doesn't itch. What does the LPN expect will be ordered for this child?
- A. Aspirin
- B. Ibuprofen
- C. Acetaminophen
- D. Antibiotics
Correct Answer: C
Rationale: Acetaminophen is safe for fever in infants, addressing the temperature while the non-itchy, blanchable rash is monitored, likely viral.