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A nurse is caring for a client who reports severe sore throat, pain when swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct Answer: D
Rationale: The correct answer is D: Illness. In this stage, the client is experiencing noticeable symptoms such as severe sore throat, pain when swallowing, and swollen lymph nodes. This indicates that the infection has progressed to the point where the body is actively fighting off the pathogen, resulting in the manifestation of symptoms. The other choices are incorrect because: A: Prodromal stage is characterized by mild, nonspecific symptoms. B: Incubation stage is the period between exposure to the pathogen and the onset of symptoms. C: Convalescence stage is the recovery period after the illness when symptoms start to improve.
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An RN is making assignments for client care to an LPN at the beginning of the shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24hr postop to use an incentive spirometer
- B. Collecting a clean-catch urine specimen from a client who was admitted on the previous shift
- C. Providing nasopharyngeal suctioning for a client who has pneumonia
- D. Replacing the cartridge and tubing on a PCA pump
Correct Answer: D
Rationale: The LPN should question assignment D (replacing the cartridge and tubing on a PCA pump) because this task involves medication administration and intravenous therapy, which are typically outside the LPN's scope of practice. LPNs are not trained to handle complex medication delivery systems like PCA pumps, as this requires specialized knowledge and skills that are within the RN's scope of practice. It is crucial for patient safety that tasks are assigned to healthcare providers based on their education, training, and scope of practice to prevent errors and ensure quality care. Assignments A, B, and C are within the LPN's scope of practice and can be safely performed without questioning.
A nurse enters a client's room & finds him sitting in his chair. He states, 'I fell in the shower, but I got myself back up & into my chair.' How should the nurse document this in the client's chart?
- A. The client fell in the shower.
- B. The client states he fell in the shower & was able to get himself back into his chair.
- C. The nurse should not document this info because she did not witness the fall.
- D. The client fell in the shower & is now resting comfortably.
Correct Answer: B
Rationale: Correct Answer: B. The client states he fell in the shower & was able to get himself back into his chair.
Rationale: This answer accurately reflects the client's own account of the events without making any assumptions. It documents both the fall and the client's ability to self-recover, which are essential details for the client's care plan.
Summary of Incorrect Choices:
A: This option only mentions the fall without acknowledging the client's ability to get back up, which is crucial information.
C: It is important to document the client's report even if the nurse did not witness the fall, as it provides valuable insight into the client's condition.
D: This option adds unnecessary information about the client's current state that is not directly related to the fall incident.
A nurse is preparing to instill an enteral feeding to a client who has an NG tube in place. What is the nurse's highest assessment priority before performing this procedure?
- A. Check how long the feeding container has been opened.
- B. Verify the placement of the NG tube.
- C. Confirm that the client doesn't have diarrhea.
- D. Make sure the client is alert & oriented.
Correct Answer: B
Rationale: The correct answer is B: Verify the placement of the NG tube. This is the highest assessment priority before instilling enteral feeding to prevent complications like aspiration. The nurse must ensure the NG tube is correctly positioned in the stomach to avoid feeding into the lungs. Checking the length of time the feeding container has been open (A) is important but not as critical as verifying tube placement. Confirming the client doesn't have diarrhea (C) is important for monitoring overall health but not directly related to the procedure. Ensuring the client is alert and oriented (D) is essential but not the priority for this specific procedure.
A nurse is caring for a client who is postoperative. Which of the following nursing interventions reduce the risk of thrombus development? Select all.
- A. Instruct the client not to use the Valsalva maneuver
- B. Apply elastic stockings
- C. Review lab values for total protein level
- D. Place pillows under the client's knees & lower extremities
- E. Assist the client to change position often
Correct Answer: B, E
Rationale: The correct answers are B and E. Applying elastic stockings helps promote circulation and prevent stasis, reducing the risk of thrombus formation. Assisting the client to change position often prevents prolonged immobility, which can lead to blood pooling and clot formation. Choice A is incorrect because the Valsalva maneuver can increase intra-abdominal pressure, potentially leading to venous stasis and thrombus formation. Choice C is irrelevant to thrombus prevention. Placing pillows under the client's knees and lower extremities (choice D) may promote comfort but does not directly reduce thrombus risk.
A nurse is assessing a client who reports pain when the nurse evaluates the internal rotation of her right shoulder. Which of the following activities is this problem likely to affect?
- A. Mopping her floors
- B. Brushing the back of her hair
- C. Fastening her bra behind her back
- D. Reaching into a cabinet above her sink
Correct Answer: C
Rationale: The correct answer is C. Fastening her bra behind her back. Internal rotation of the shoulder is necessary for this activity as it involves reaching the arm behind the body. Mopping the floors (A) and brushing the back of her hair (B) primarily require shoulder abduction and flexion. Reaching into a cabinet above the sink (D) involves shoulder flexion and abduction, not internal rotation.