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A nurse has an order to remove sutures from a client. After retrieving the suture removal kit and applying sterile gloves, which of the following actions should the nurse take next?
- A. Clean sutures along the incision site.
- B. Remove sutures using sterile technique.
- C. Inspect the wound for signs of infection.
- D. Document the removal of sutures.
Correct Answer: B
Rationale: After applying sterile gloves, the nurse should proceed to remove the sutures using sterile technique. This step ensures the safe and effective removal of sutures without introducing infection. Choice A, cleaning sutures along the incision site, would not be the next step as the primary focus is on suture removal. Inspecting the wound for signs of infection (Choice C) is important but typically follows suture removal. Documenting the removal of sutures (Choice D) is essential but usually occurs after the procedure is completed.
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When providing oral care for an unconscious client, which of the following actions should the nurse take?
- A. Place the client in a lateral position with the head turned to the side before beginning the procedure.
- B. Insert a suction catheter before brushing the teeth.
- C. Use a soft-bristled toothbrush only with water.
- D. Brush the client's teeth while they are in a supine position.
Correct Answer: A
Rationale: When providing oral care for an unconscious client, it is essential to place them in a lateral position with the head turned to the side before beginning the procedure. This positioning helps prevent aspiration by allowing fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Inserting a suction catheter before brushing the teeth (Choice B) is not recommended as it can cause discomfort and increase the risk of oral tissue injury. Using a soft-bristled toothbrush only with water (Choice C) is not sufficient for effective oral care as toothpaste helps in removing plaque and bacteria. Brushing the client's teeth while they are in a supine position (Choice D) is not safe as it increases the risk of aspiration since fluids can easily enter the airway in this position.
A client with a history of deep vein thrombosis (DVT) is admitted with swelling and pain in the left leg. What is the most appropriate action for the LPN/LVN to take?
- A. Apply warm compresses to the affected leg.
- B. Elevate the left leg above the level of the heart.
- C. Measure the circumference of the left leg.
- D. Administer pain medication as prescribed.
Correct Answer: C
Rationale: Measuring the circumference of the left leg is the most appropriate action for an LPN/LVN when assessing a client with a history of DVT and presenting with swelling and pain in the left leg. This measurement helps to assess the extent of swelling objectively and monitor changes in the client's condition. Applying warm compresses (Choice A) may worsen the condition by potentially promoting clot development. Elevating the left leg above the level of the heart (Choice B) is generally recommended for DVT to improve venous return, but measuring the circumference is more appropriate in this scenario. Administering pain medication (Choice D) does not address the underlying issue and should not be the initial action taken.
When ambulating a frail, older adult client, the nurse should:
- A. Use the transfer belt if the client is unsteady
- B. Walk beside the client without support
- C. Encourage the client to use a walker
- D. Hold the client's arm for support
Correct Answer: A
Rationale: Using a transfer belt if the client is unsteady is essential to provide added safety and support during ambulation. This device helps the nurse assist the client in maintaining balance and prevents falls. Walking beside the client without support (choice B) may not offer enough assistance for a frail, older adult who is unsteady. Encouraging the client to use a walker (choice C) could be helpful in some cases, but if the client is unsteady during ambulation, additional support like a transfer belt is more appropriate. Holding the client's arm for support (choice D) may not provide enough stability and safety compared to using a transfer belt.
A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the LPN/LVN implement first?
- A. Assist the ambulating client back to the bed.
- B. Encourage the client to ambulate to resolve pneumonia.
- C. Obtain a prescription for portable oxygen while ambulating.
- D. Move the oximetry probe from the finger to the earlobe.
Correct Answer: A
Rationale: The correct intervention is to assist the client back to bed. A decrease in oxygen saturation while ambulating indicates hypoxemia, and the immediate priority is to stabilize oxygen levels. Returning the client to bed allows for rest and decreased oxygen demand, potentially preventing further desaturation. Encouraging continued ambulation (Choice B) may worsen the hypoxemia by increasing oxygen demand. Obtaining portable oxygen (Choice C) is essential but should not delay addressing the low oxygen saturation. Moving the oximetry probe (Choice D) may not address the underlying cause of decreased oxygen saturation and should not be the first intervention.
The healthcare provider is assessing a 17-month-old with acetaminophen poisoning. Which lab reports should the provider review first?
- A. Prothrombin time (PT) and partial thromboplastin time (PTT)
- B. Red blood cell and white blood cell counts
- C. Blood urea nitrogen and creatinine levels
- D. Liver enzymes (AST and ALT)
Correct Answer: D
Rationale: In acetaminophen poisoning, liver damage is a significant concern due to the potential for hepatotoxicity. Therefore, the healthcare provider should first review liver enzymes such as AST (aspartate aminotransferase) and ALT (alanine aminotransferase) to assess liver function. Prothrombin time and partial thromboplastin time are coagulation studies and are not the priority in acetaminophen poisoning. Red blood cell and white blood cell counts are important in assessing for anemia or infection but are not specific to acetaminophen poisoning. Blood urea nitrogen and creatinine levels primarily assess kidney function, which is not the primary concern in acetaminophen poisoning.