Nokea
A transfusion is ordered for a hospitalized client. The charge nurse asks the LPN to start the transfusion. What should the LPN do?
- A. Start the transfusion as ordered
- B. Be sure that dextrose is hanging and then hang the blood
- C. Tell the RN that LPNs are not allowed to hang blood
- D. Hang the blood only if an IV line is already established
Correct Answer: C
Rationale: LPNs typically cannot initiate blood transfusions due to scope of practice limitations, as it requires specialized monitoring, so the LPN should inform the RN.
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For a 6 year-old child hospitalized with moderate edema and mild hypertension associated with acute glomerulonephritis (AGN), which one of the following nursing interventions would be appropriate?
- A. Institute seizure precautions
- B. Weigh the child twice per shift
- C. Encourage the child to eat protein-rich foods
- D. Relieve boredom through physical activity
Correct Answer: A
Rationale: Institute seizure precautions. The severity of AGN is unpredictable, and complications like seizures may occur due to hypertension.
The nurse approaches a 4-year-old boy to administer a medication. The child has no identification armband. Which action is most appropriate?
- A. Check the room and bed number the child is in with the room and bed number on the medication order and administer the medication if they agree
- B. Ask the child what his name is before administering the medication
- C. Ask the child if his name is George (the name on the medication order) and administer the medication if the child says that is his name
- D. Ask the adults at the bedside what the child's name is and administer the medication if the adults verify the name of the child
Correct Answer: D
Rationale: Verifying the child's identity with adults at the bedside ensures safety, as children may not reliably confirm their own identity, and room/bed numbers are not sufficient for identification.
The doctor has ordered an IV of magnesium sulfate for a G1 P0 with preeclampsia. Which of the following symptoms is an expected side effect of magnesium sulfate?
- A. Oliguria
- B. Hypersomnolence
- C. Hyporeflexia
- D. Bradypnea
Correct Answer: C
Rationale: Hyporeflexia is an expected side effect of magnesium sulfate, used to monitor for toxicity in preeclampsia treatment.
The nurse is caring for a client who reported having thoughts of self-injury yesterday. Which of the following statements by the client should the nurse recognize as risk factors for suicide? Select all that apply.
- A. I am currently unemployed and looking for a job
- B. I have been married for five years with three children
- C. I have multiple firearms at home stored in a safe
- D. I have been about a year since I last overdosed
- E. I attend weekly religious activities with my family
- F. Sometimes I experience feelings of hopelessness
Correct Answer: A,C,D,F
Rationale: Unemployment, access to firearms, prior overdose, and hopelessness are established suicide risk factors. Marriage with children and religious activities are protective factors.
A school nurse is advising a class of unwed pregnant high school students. What is the most important action they can perform to deliver a healthy child?
- A. Maintain good nutrition
- B. Stay in school
- C. Keep in contact with the child's father
- D. Get adequate sleep
Correct Answer: A
Rationale: Maintain good nutrition. Adequate nutrition, especially protein, vitamins, and iron, is critical for healthy fetal development and reducing low-birth-weight risks.