Nokea
A student nurse arrives on the unit and asks you what the rationale for treatment of withdrawal is. What is the best response?
- A. To protect the patient while the body removes the drug from the patient's bloodstream.
- B. To protect the patient from relapsing during withdrawal.
- C. To treat the patient's psychological dependency on the substance.
- D. To treat the symptoms of withdrawal while the body removes the substance from the patient's bloodstream.
Correct Answer: D
Rationale: Treating withdrawal symptoms supports physiological stability as the body clears the substance.
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For care of a patient who has oral cancer, which task would be appropriate to delegate to the LPN/LVN?
- A. Assist the patient to brush and floss.
- B. Give antacids and sucralfate suspension as ordered.
- C. Recommend saliva substitutes.
- D. Explain when brushing and flossing are contraindicated.
Correct Answer: A
Rationale: Assisting with oral hygiene is within the scope of practice for LPNs/LVNs, while medication administration and patient education require higher-level training.
What type of shock is the client experiencing if there is no urine return after inserting a Foley catheter?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Decreased blood pressure is a primary symptom in fluid imbalance as a result of inadequate circulating volume, leading to hypotension and possible shock.
The nurse is reviewing the laboratory results for a preoperative patient. Which test result should be brought to the attention of the surgeon immediately?
- A. Serum K+ of 3.8 mEq/L
- B. Hemoglobin of 15 g/dL
- C. Blood glucose of 100 mg/dL
- D. White blood cell (WBC) count of 18,500/µL
Correct Answer: D
Rationale: An elevated WBC count indicates potential infection, requiring immediate attention.
Which physical assessment finding should be reported to the physician?
- A. Pearly gray or pink tympanic membrane
- B. Dense, whitish ring at the circumference of the tympanum
- C. Bulging red or blue tympanic membrane
- D. A cone of light at the innermost part of the tympanum
Correct Answer: C
Rationale: A bulging red or blue tympanic membrane indicates acute otitis media or other serious conditions requiring medical intervention.
The most important laboratory value to monitor in a patient with heavy bleeding due to fibroids is:
- A. Hemoglobin
- B. Luteinizing hormone
- C. White blood cell count
- D. Potassium
Correct Answer: A
Rationale: Hemoglobin levels are critical to assess the severity of blood loss and anemia in patients with heavy bleeding.