Nokea
A nurse is teaching an adult client how to administer ear drops. Which of the following statements by the client indicates understanding of the proper technique?
- A. I will straighten my ear canal by pulling my ear down & back.
- B. I will gently apply pressure w/my finger to the tragus of my ear after putting in the drops.
- C. I will insert the nozzle of the ear drop bottle snug into my ear before squeezing the drops in.
- D. After the drops are in, I will place a cotton ball all the way into my ear canal.
Correct Answer: B
Rationale: The correct answer is B: "I will gently apply pressure with my finger to the tragus of my ear after putting in the drops." This statement indicates understanding of the proper technique because applying pressure to the tragus helps the ear drops to reach the ear canal. The tragus is a small cartilaginous projection in front of the ear canal that, when pressed, helps to facilitate the passage of the drops into the ear. This action ensures proper distribution of the medication for effective treatment.
Other choices are incorrect:
A: Pulling the ear down and back is a technique used for administering ear drops in children, not adults.
C: Inserting the nozzle snug into the ear can cause injury to the ear canal and eardrum.
D: Placing a cotton ball all the way into the ear canal can prevent the drops from reaching the ear canal and may cause blockage.
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A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all.
- A. Fever
- B. Malaise
- C. Edema
- D. Pain or tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A, B, E
Rationale: The correct answer is A, B, E. Fever is a common systemic response to infection as the body raises its temperature to help fight off pathogens. Malaise, a general feeling of discomfort or uneasiness, is also a systemic manifestation indicating a more widespread infection affecting overall well-being. An increase in pulse and respiratory rate can indicate systemic involvement as the body tries to cope with the infection. Edema, pain, or tenderness are more indicative of localized infections and not typically seen in systemic infections.
A nurse is caring for a client who presents with linear clusters of fluid-containing vesicles with some crusting. Which of the following should the nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The presentation of linear clusters of fluid-containing vesicles with crusting is characteristic of herpes zoster, also known as shingles. This viral infection is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution of the vesicles along a dermatome is a key feature of herpes zoster. The other choices are incorrect because: A: Allergic reactions typically present with hives or itching, not vesicles with crusting. B: Ringworm presents as circular, red, scaly patches, not linear clusters of vesicles. C: Systemic lupus erythematosus is an autoimmune disease that manifests with a butterfly rash on the face, joint pain, and other systemic symptoms, not vesicles. Therefore, the nurse should suspect herpes zoster based on the presentation described.
A client who has had a cerebrovascular accident has persistent problems w/dysphagia. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team? Select all.
- A. Social worker
- B. CNA
- C. Occupational therapist
- D. Speech-language pathologist
Correct Answer: C, D
Rationale: The correct answer is C and D. The occupational therapist (C) can help with improving the client's ability to eat independently by providing adaptive equipment and strategies. A speech-language pathologist (D) is crucial for assessing and treating dysphagia to prevent aspiration and improve swallowing function. The social worker (A) may address psychosocial needs but does not directly address dysphagia. The CNA (B) primarily assists with daily living activities.
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 is caring for a client who is on a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?
- A. Cooked barley
- B. Pureed broccoli
- C. Vanilla custard
- D. Lentil soup
Correct Answer: C
Rationale: The correct answer is C: Vanilla custard. A low-residue diet aims to minimize fiber intake to reduce the bulk and frequency of bowel movements. Vanilla custard is low in fiber, making it suitable for this diet. Cooked barley (A) and lentil soup (D) are high in fiber and not recommended. Pureed broccoli (B) contains fiber and should be avoided. In summary, vanilla custard is the best choice for a low-residue diet due to its low fiber content compared to the other options.