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All of the following tasks need to be done. Which one can the LPN/LVN safely delegate to the certified nursing assistant (CNA)?
- A. Tube feeding for a client with a nasogastric tube
- B. Routine vital signs for a group of clients
- C. Blood pressure monitoring for a client who is in congestive heart failure
- D. Wound care for a client with a stage III decubitus ulcer
Correct Answer: B
Rationale: Routine vital signs are within a CNA's scope of practice. Tube feeding, specialized blood pressure monitoring, and wound care require nursing judgment and skills.
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The health care provider prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication?
- A. I can stop taking the medication once my symptoms improve
- B. I must eat a healthy diet and exercise regularly to reduce weight gain
- C. I should feel better within 1 week after starting this medication
- D. I will experience improved sexual performance with this medication
Correct Answer: B
Rationale: Paroxetine may cause weight gain, so a healthy diet and exercise are appropriate. Stopping abruptly risks withdrawal, full effects take weeks, and sexual dysfunction is a common side effect.
The nurse is teaching a client about newly prescribed amlodipine. Which adverse effect would be most important for the nurse to include?
- A. Depression
- B. Dizziness
- C. Dry cough
- D. Erectile dysfunction
Correct Answer: B
Rationale: Dizziness, due to amlodipine’s vasodilatory effect, is a common and critical side effect, risking falls, especially in the elderly. Depression, cough, and erectile dysfunction are less common or associated with other drugs.
The nurse in an outpatient clinic is caring for a client at 34 weeks gestation. The client is taking ferrous sulfate for anemia and reports constipation. Which of the following recommendations should the nurse reinforce for this client? Select all that apply.
- A. Decreased daily intake of dairy products
- B. Increased intake of fruits and vegetables
- C. Moderate-intensity exercise regularly
- D. One stimulant laxative daily for a week
- E. Two cups of hot coffee each morning
Correct Answer: B,C
Rationale: Fruits and vegetables provide fiber, and exercise promotes bowel motility, relieving constipation. Dairy may worsen constipation, stimulant laxatives are not first-line in pregnancy, and coffee is not a primary solution.
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.
A couple asks the nurse about risks of several birth control methods. What is the most appropriate response by the nurse?
- A. Norplant is safe and may be removed easily
- B. Oral contraceptives should not be used by smokers
- C. Depo-Provera is convenient with few side effects
- D. The IUD gives protection from pregnancy and infection
Correct Answer: B
Rationale: Oral contraceptives should not be used by smokers. The use of oral contraceptives in a woman who smokes increases her risk of cardiovascular problems, such as thromboembolic disorders.