Nokea
A nurse is reading the nurse practice act for the state in which she is employed. The nurse uses the information in this act for which purpose?
- A. To understand hospital and long-term care facility policies
- B. To know the scope of practice for nurses
- C. To identify health care policies in her state
- D. To be aware of the role of the licensed nurse
Correct Answer: D
Rationale: The correct answer is 'To be aware of the role of the licensed nurse.' Nurse practice acts outline the scope of practice for nurses, defining what constitutes nursing practice and the role of licensed nurses. Choice A is incorrect because hospital and long-term care facility policies are institution-specific and not typically covered in the nurse practice act. Choice B is incorrect as the scope of practice for nurses is a part of the nurse practice act, but it's not the sole purpose for a nurse to refer to it. Choice C is incorrect as health care policies in a state are governed by other legislative acts, not the nurse practice act.
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A client with which of the following conditions is at risk for developing a high ammonia level?
- A. renal failure
- B. psoriasis
- C. lupus
- D. cirrhosis
Correct Answer: D
Rationale: Cirrhosis is the correct answer. In cirrhosis, the liver is unable to detoxify ammonia to urea, leading to an accumulation of ammonia in the blood. This can result in hepatic encephalopathy, a condition characterized by high ammonia levels affecting brain function. Renal failure (Choice A), psoriasis (Choice B), and lupus (Choice C) are not directly associated with an increased risk of high ammonia levels as seen in cirrhosis.
Which of the following tasks are appropriate for an LPN to perform?
- A. Adjusting the cervical traction device of a 68-year-old client as instructed by the charge nurse.
- B. performing operation on a woman in labour
- C. Assessing a 36-year-old man newly admitted for chest pain.
- D. Obtaining an occult blood sample from a 16-year-old client with ulcerative colitis.
Correct Answer: D
Rationale: Tasks appropriate for an LPN to perform include teaching, obtaining samples, and documenting. LPNs can educate clients on care practices, such as teaching a new mother how to care for her baby. Obtaining samples, like an occult blood sample, falls within the scope of an LPN's responsibilities. Assessments, especially initial assessments, should be conducted by a registered nurse or physician, making option C incorrect. Adjusting devices like a cervical traction device should be done based on direct orders from prescribing providers, not charge nurses, making option A inappropriate for an LPN's role.
The nurse notes that a healthcare provider has documented the following prescription in a client's record: Furosemide (Lasix) 40 mg stat once. What action should the nurse take?
- A. Administering the medication
- B. Drawing up the medication in a syringe
- C. Planning to have the nurse on the next shift administer the medication
- D. Contacting the healthcare provider
Correct Answer: D
Rationale: The correct action for the nurse to take in this situation is to contact the healthcare provider. The prescription provided lacks crucial information such as the route of administration. Before administering any medication, the nurse must clarify any missing details with the provider, especially for a stat prescription that requires immediate administration. Drawing up or administering the medication without verifying the route of administration is unsafe and can lead to errors. Planning for the next shift nurse to administer the medication is not appropriate in this scenario as the stat order necessitates immediate action. Therefore, the best course of action is to contact the healthcare provider to obtain clarification on the prescription.
How many feet should separate the nurse and the source when extinguishing a small, wastebasket fire with an appropriate extinguisher?
- A. 1 foot
- B. 2 feet
- C. 4 feet
- D. 6 feet
Correct Answer: D
Rationale: The nurse should stand about 6 feet from the source of the fire. Getting closer might put the nurse in danger. Choice A, 1 foot, is incorrect because it is too close to the fire and can expose the nurse to unnecessary risk. Choice B, 2 feet, is also too close to the fire and may lead to potential harm. Similarly, choice C, 4 feet, is not the ideal distance as it is still within the range of potential danger. The correct answer is D, 6 feet, which is a safe distance for the nurse to extinguish the fire effectively without risking personal safety.
The nurse teaching a client about hepatitis and its transmission should explain that one type of hepatitis does not produce a carrier state after its acute phase. Which type is it?
- A. hepatitis A
- B. hepatitis B
- C. hepatitis C
- D. hepatitis D
Correct Answer: A
Rationale: The correct answer is hepatitis A. Hepatitis A does not produce a carrier state after its acute phase. It is transmitted via contaminated water or food through the oral-fecal route and is not blood-borne. Hepatitis B, choice B, can lead to a carrier state where the person remains infectious despite being asymptomatic. Hepatitis C, choice C, can also result in a chronic carrier state. Hepatitis D, choice D, is an incomplete virus that requires hepatitis B to replicate; it does not lead to a carrier state on its own.