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A nurse is assisting with data collection of a client who has sustained circumferential burns of both legs. What should the nurse examine first?
- A. Heart rate
- B. Peripheral pulses
- C. Blood pressure (BP)
- D. Radial pulse rate
Correct Answer: B
Rationale: The priority assessment for a client with circumferential burns to the legs is to examine peripheral pulses. This is essential to ensure adequate circulation to the extremities. Circumferential burns can lead to compartment syndrome, causing decreased circulation to the affected limbs. Checking peripheral pulses is crucial to monitor for any signs of compromised circulation. While heart rate and blood pressure are important assessments in general, in the context of circumferential burns, the immediate concern is the risk of impaired circulation to the extremities. Therefore, assessing peripheral pulses takes precedence in this situation.
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Which of these clients should the LPN/LVN see first?
- A. a client with a newly placed NG tube who is complaining of pain around the face and a plugged nose
- B. a post-op prostatectomy client who complains of bladder spasms and blood in his foley bag
- C. a client in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm
- D. a client newly diagnosed with Hepatitis A who reports stomach pain and itchy skin
Correct Answer: C
Rationale: Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a medical provider right away. This is a potential emergency situation that requires immediate attention to prevent complications. The other options present expected or typical symptoms related to their diagnosis, which do not require immediate intervention. Complaints related to a newly placed NG tube such as pain around the face and a plugged nose may require assessment and intervention but are not as urgent as potential compartment syndrome. Bladder spasms and blood in the foley bag post-prostatectomy are common postoperative issues that can be addressed after the client in the arm cast with potential compartment syndrome is seen. Stomach pain and itchy skin in a client with Hepatitis A are common symptoms of the condition and do not indicate an emergency situation.
The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?
- A. Monitoring for bleeding for a client who has just undergone cardiac catheterization
- B. Assisting a client who is getting up to ambulate for the first time after surgery
- C. Providing oral care to an unconscious client who requires oral care
- D. Completing the preoperative checklist for a client scheduled for a liver biopsy
Correct Answer: C
Rationale: When delegating tasks, the nurse must consider the state nursing practice act guidelines and job descriptions. Providing oral care to an unconscious client is a task suitable for delegation to a nursing assistant. The nurse should give clear instructions on adapting the procedure for the client's needs and the signs of complications to watch for. Monitoring for bleeding after cardiac catheterization necessitates immediate nursing assessment, which requires critical thinking and intervention that exceeds a nursing assistant's scope of practice. Assisting a client with ambulation post-surgery carries the risk of orthostatic hypotension and should be performed by a licensed nurse. Completing a preoperative checklist for a client scheduled for a liver biopsy involves critical assessment and preparation that are within the nurse's scope of practice.
A client admitted to the hospital has a do-not-resuscitate (DNR) order in his medical record. The nurse understands which information about DNR orders?
- A. The only individuals who may change the DNR order are healthcare providers
- B. The DNR order can be changed if the client's condition warrants it
- C. The DNR order does not remain fixed for the duration of the client's hospitalization
- D. The DNR order requires frequent review as specified by state or agency policy
Correct Answer: D
Rationale: The correct answer is that the DNR order requires frequent review as specified by state or agency policy. If the client's condition changes, the DNR order may need to be changed. For this reason, DNR orders require frequent review as specified by state or agency policy. A DNR order may be changed at any time and does not remain in effect for the duration of the client's hospitalization. The client's request regarding DNR status is the priority. Choice A is incorrect because healthcare providers, not just immediate family members, may change the DNR order based on the client's condition. Choice B is incorrect as DNR orders can be changed if the client's condition warrants it, not remaining unchanged. Choice C is incorrect as DNR orders are not fixed for the duration of hospitalization, they can be modified based on the client's needs.
When planning task assignments for five clients on the skilled nursing unit in a long-term care facility, which task should a licensed practical nurse (LPN) assign to another LPN?
- A. Bathing a client who is confused and requires assistance with a shower
- B. Administering regular insulin in accordance with a sliding-dosage scale every 4 hours to a client with diabetes mellitus
- C. Assisting a client requiring a bed bath and frequent ambulation with a cane
- D. Transporting a client who must be accompanied to physical therapy twice during the shift
Correct Answer: B
Rationale: When assigning tasks, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned tasks like caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to administer medications like regular insulin in accordance with a sliding scale. This task requires a higher level of training and knowledge than the tasks that can be delegated to a nursing assistant. Administering insulin involves assessing blood glucose levels, calculating dosages, and understanding the effects of insulin therapy on the client's condition. Therefore, the correct answer is administering regular insulin to a client with diabetes mellitus. Choices A, C, and D involve tasks that are within the scope of practice of a nursing assistant, not an LPN.
All of the following interventions should be performed when fetal heart monitoring indicates fetal distress except:
- A. Increase maternal fluids.
- B. Administer oxygen.
- C. Decrease maternal fluids.
- D. Turn the mother.
Correct Answer: C
Rationale: When fetal heart monitoring indicates fetal distress, interventions are aimed at improving oxygenation to the fetus. Increasing maternal fluids helps improve placental perfusion and oxygen delivery to the fetus. Administering oxygen also aids in increasing oxygen supply to the fetus. Turning the mother can help relieve pressure on the vena cava, optimizing blood flow to the placenta. Therefore, decreasing maternal fluids would not be performed as it can further compromise placental perfusion and fetal oxygenation, making it the exception. Decreasing maternal fluids could potentially exacerbate fetal distress by reducing oxygen delivery and nutrient supply to the fetus, which is contrary to the goal of managing fetal distress.