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A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube. Which of the following actions should the nurse take?
- A. Remove the restraints every 4 hours.
- B. Attach the restraints securely to the side of the client's bed.
- C. Apply the restraints to allow as little movement as possible.
- D. Allow room for two fingers to fit between the client's skin and the restraints.
Correct Answer: D
Rationale: When using wrist restraints, it is important to allow room for two fingers to fit between the client's skin and the restraints. This practice ensures proper circulation and comfort for the client while still providing the necessary level of security. Choice A is incorrect because removing restraints every 4 hours may compromise the effectiveness of restraint use. Choice B is incorrect as restraints should not be attached to the side of the bed where they could cause harm or be tampered with by the client. Choice C is incorrect because allowing minimal movement may lead to discomfort and compromise proper circulation.
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A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?
- A. Apply the cuff above the client's antecubital fossa.
- B. Use a cuff with a width that is about 60% of the client's arm circumference.
- C. Have the client sit with their arm resting at the level of their heart.
- D. Release the pressure on the client's arm at a rate of 5 to 6 mm per second.
Correct Answer: A
Rationale: The correct action when checking a client's blood pressure is to apply the cuff above the client's antecubital fossa. Placing the cuff above this area allows for an accurate measurement of blood pressure. Choice B is incorrect because the cuff width should be approximately 40% of the arm circumference, not 60%. Choice C is incorrect as the client's arm should rest at heart level, not above it, to ensure an accurate reading. Choice D is incorrect as the pressure on the client's arm should be released at a rate of 2 to 3 mm per second, not 5 to 6 mm per second.
After completing an assessment and determining that a client has a problem, what should the LPN/LVN do next?
- A. Determine the etiology of the problem.
- B. Prioritize nursing care interventions.
- C. Plan appropriate interventions.
- D. Collaborate with the client to set goals.
Correct Answer: A
Rationale: After identifying a problem in a client, the next step for the LPN/LVN is to determine the etiology or cause of the problem. Understanding the root cause of the issue is essential as it guides the development of appropriate interventions. Option B, prioritizing nursing care interventions, is premature without knowing the cause of the problem. Option C, planning appropriate interventions, also relies on knowing the etiology first to ensure the interventions directly address the underlying issue. Collaborating with the client to set goals, as mentioned in option D, is important but typically comes after understanding the cause of the problem to ensure the goals are relevant and effective.
A client is talking with an older adult who is contemplating retirement. The client states, 'I keep thinking about how much I enjoy my job. I'm not sure I want to retire.' Which of the following responses should the nurse make?
- A. Let's talk about how the change in your job status will affect you.
- B. You should consider how retirement will affect your financial situation.
- C. Retirement is a big change, take your time to decide.
- D. Have you thought about what you will do after you retire?
Correct Answer: A
Rationale: The correct response is to discuss how the change in job status will affect the client. This helps the client consider the emotional and psychological impact of retirement. Choice B focuses solely on the financial aspect of retirement, which may not address the client's current concerns about enjoying their job. Choice C acknowledges the decision-making process but does not actively engage the client in exploring their feelings. Choice D shifts the focus to post-retirement plans without addressing the client's current hesitation about retiring.
A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse with inspiration. The nurse auscultates a high-pitched scratching sound during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document?
- A. Pericardial friction rub
- B. Mitral stenosis
- C. Aortic regurgitation
- D. Tricuspid stenosis
Correct Answer: B
Rationale: The correct answer is B: Mitral stenosis. A high-pitched scratching sound heard during both systole and diastole with the diaphragm of the stethoscope positioned at the left sternal border indicates mitral stenosis, not a pericardial friction rub. Pericardial friction rub is a to-and-fro, grating, or scratching sound due to inflamed pericardial surfaces rubbing together, typically heard in early diastole and late systole. Aortic regurgitation and tricuspid stenosis would present with different auscultatory findings compared to the described scenario, making them incorrect choices in this context.
A healthcare professional is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?
- A. HR 105/min
- B. BMI 25 kg/m²
- C. BP 148/92
- D. Glucose 45 mg/dL
Correct Answer: D
Rationale: The correct answer is D, 'Glucose 45 mg/dL.' Glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition requiring immediate attention to prevent complications like seizures, loss of consciousness, and even coma. Hypoglycemia can lead to serious adverse outcomes if not promptly addressed. Choices A, B, and C do not represent immediate life-threatening conditions and can be managed as part of routine care, unlike hypoglycemia which demands urgent intervention.