Nokea
A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP?
- A. Using a cuff that is too small will result in an inaccurately high reading.
- B. Using a cuff that is too large will result in an inaccurately low reading.
- C. The regular size cuff is appropriate for all clients.
- D. You should use a cuff of any size as long as it fits.
Correct Answer: A
Rationale: The correct answer is A: 'Using a cuff that is too small will result in an inaccurately high reading.' When obtaining blood pressure for an obese client, it is crucial to use a larger cuff to ensure an accurate reading. Choice B is incorrect because using a cuff that is too large for an obese client would actually result in an inaccurately low reading. Choice C is incorrect as a regular size cuff is not appropriate for obese clients due to their larger arm circumference. Choice D is incorrect because using a cuff of any size as long as it fits is not suitable for obtaining accurate blood pressure readings on an obese client.
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A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?
- A. "Rashes are very common, especially if you have dry skin. Did it go away on its own?"
- B. "Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotic."
- C. "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash."
- D. "We need to document the exact medication you were taking because you might be allergic to it."
Correct Answer: D
Rationale: The correct answer is D. If a client reports developing a rash when taking a specific medication, even if they are not aware of any allergies, it is crucial to document this information. This is necessary to prevent future allergic reactions. Identifying the exact medication that caused the rash is essential as the client could have an allergy to it. Providing this information allows healthcare providers to avoid prescribing the same medication again, which could potentially lead to more severe allergic reactions or life-threatening situations. Choices A, B, and C are incorrect because they do not address the importance of documenting the specific medication that caused the adverse reaction or the potential risks of repeating the medication. Simply attributing the rash to common occurrences, adverse effects of medications in general, or assuming the rash is insignificant in the current context can overlook the critical aspect of identifying and avoiding allergens.
While assisting a client with a meal, the client suddenly grabs at their neck with both hands and appears frightened. The appropriate nursing action is to:
- A. Ask the client if they are choking
- B. Perform abdominal thrusts
- C. Call for emergency help
- D. Check the client's airway
Correct Answer: A
Rationale: The correct action when a client suddenly grabs at their neck and appears frightened is to ask if they are choking. This allows the nurse to gather more information from the client directly. Performing abdominal thrusts (choice B) should only be done if the client is unable to speak, cough, or breathe. Calling for emergency help (choice C) should be done after assessing the situation and confirming choking. Checking the client's airway (choice D) is important but should come after confirming that the client is choking.
The nurse is providing discharge instructions to a client who has been prescribed an iron supplement. Which statement by the client indicates a need for further teaching?
- A. I should take the supplement with milk to increase absorption.
- B. I should expect my stools to turn black while taking this supplement.
- C. I should take the supplement with a full glass of water.
- D. I should take the supplement on an empty stomach.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When conducting an admission assessment, the LPN should ask the client about the use of complementary healing practices. Which statement is accurate regarding the use of these practices?
- A. Complementary healing practices interfere with the efficacy of the medical model of treatment.
- B. Conventional medications are likely to interact with folk remedies and cause adverse effects.
- C. Many complementary healing practices can be used in conjunction with conventional practices.
- D. Conventional medical practices will ultimately replace the use of complementary healing practices.
Correct Answer: C
Rationale: When considering the use of complementary healing practices, it is important to acknowledge that many of these practices can be safely integrated with conventional treatments to provide holistic care. Choice A is incorrect because complementary healing practices can complement traditional medical approaches rather than interfere with their efficacy. Choice B is incorrect as interactions between conventional medications and folk remedies may vary, but not all interactions lead to adverse effects. Choice D is incorrect as conventional medical practices and complementary healing practices can coexist and each offer benefits in healthcare.
During auscultation of the anterior chest wall of a client newly admitted to a medical-surgical unit, what type of breath sounds should a nurse expect to hear?
- A. Normal breath sounds
- B. Adventitious breath sounds
- C. Absent breath sounds
- D. Diminished breath sounds
Correct Answer: A
Rationale: During auscultation of the chest, normal breath sounds are the expected findings in a client who is newly admitted without respiratory complaints. Normal breath sounds indicate proper airflow through the airways without any abnormalities. Adventitious breath sounds (Choice B) refer to abnormal lung sounds such as crackles or wheezes, which are indicative of underlying respiratory issues. Absent breath sounds (Choice C) suggest a lack of airflow to a particular lung area, which could be due to conditions like pneumothorax. Diminished breath sounds (Choice D) indicate reduced airflow or consolidation in a specific lung region, often seen in conditions like pleural effusion or pneumonia. Therefore, in a newly admitted client without respiratory complaints, the nurse should expect to hear normal breath sounds during auscultation.