Nokea
All of the following clients assigned to LPN/LVN ring their call bells. Which client needs the most immediate attention?
- A. A 72-year-old diabetic who is blind says she has to go to the bathroom.
- B. A 75-year-old client who has rheumatoid arthritis asks for pain medication.
- C. A client who has a blood transfusion running says her chest hurts.
- D. A postoperative client says he is in pain and wants a pain shot.
Correct Answer: C
Rationale: Chest pain during a blood transfusion suggests a possible transfusion reaction, a life-threatening emergency requiring immediate intervention. Bathroom needs, arthritis pain, or postoperative pain are less urgent.
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A client continually repeats phrases that others have just said. The nurse recognizes this behavior as
- A. Autistic
- B. Echopraxis
- C. Echolalia
- D. Catatonic
Correct Answer: C
Rationale: Echolalia is repeating words or phrases heard before, often seen in certain psychiatric or developmental conditions.
The nurse is caring for a hospitalized client. Which is the best example of narrative documentation to provide legal malpractice protection for the nurse after an adverse event?
- A. Client found on floor this morning at 6:50 AM. No verbalized symptoms. I think client tripped over a cord. Client instructed on safety during ambulation.'
- B. Client reports IV pole hit head at 7:30 AM. Denies pain. IV pole removed for client safety. Will continue to monitor. Health care provider (HCP) notified.'
- C. IV site in right hand is red and swollen at 9:30 AM. IV line removed, bleeding controlled, and warm compress administered at 9:40 AM. Will monitor for swelling and pain every hour.'
- D. Package of green leaves found in client drawer at 1:00 PM. Client acting suspicious at 2:00 PM. HCP notified. Will call security. Client has multiple tattoos and piercings.'
Correct Answer: C
Rationale: Detailed, objective documentation (C) with times, actions, and follow-up plans provides the best legal protection. Options A, B, and D include assumptions, vague details, or irrelevant information.
The nurse performs an assessment during a fluid exchange for the client who is 48 hours post-insertion of an abdominal Tenckhoff catheter for peritoneal dialysis. The nurse knows that the appearance of which of the following needs to be reported to the provider immediately?
- A. slight pink-tinged drainage
- B. abdominal discomfort
- C. muscle weakness
- D. cloudy drainage
Correct Answer: D
Rationale: Cloudy drainage is a sign of infection that can lead to peritonitis (inflammation of the peritoneum). The other options are expected side effects of peritoneal dialysis.
The nurse is caring for a client with tuberculosis who is on airborne isolation precautions. The nurse can delegate which tasks to experienced unlicensed assistive personnel? Select all that apply.
- A. Alert the x-ray department about maintaining airborne isolation precautions
- B. Explain to the client why the client must wear a mask during transport to another department
- C. Post signs for airborne isolation precautions on the client's door and stock necessary equipment
- D. Remind visitors to wear a respirator mask and keep the door closed while in the client's room
- E. Talk with the family about the reasons for airborne isolation precautions in the client
Correct Answer: C, D
Rationale: Posting signs and stocking equipment (C) and reminding visitors about precautions (D) are within UAP scope. Alerting departments (A), explaining to the client (B), and educating family (E) require nursing judgment.
The nurse just administered routine immunizations to a healthy 15-month-old. What information should the nurse reinforce with the caregivers before they leave the clinic?
- A. Call the office if the toddler's temperature is higher than 100 F (37.7 C)
- B. Fussiness and anorexia are common for 1 week after immunizations
- C. Redness at the injection sites and a mild fever are common
- D. The toddler's activity level should be restricted for 24 hours
Correct Answer: C
Rationale: Redness and mild fever (C) are common post-immunization reactions. A temperature above 100 F (A) is too low a threshold for concern, fussiness for a week (B) is excessive, and activity restriction (D) is unnecessary.