Nokea
An adult is being discharged from the emergency room with instructions to apply a cold pack to his sprained ankle. The client asks why it is necessary to use a cold pack. The nurse replies that the cold pack will do which of the following?
- A. Keep the sprain from becoming a fracture
- B. Prevent bruising and ecchymosis from occurring
- C. Keep the client from developing a fever
- D. Help reduce swelling and pain
Correct Answer: D
Rationale: Cold packs reduce swelling and pain by constricting blood vessels and numbing the area, aiding sprain recovery. They don't prevent fractures, bruising, or fever.
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A laboring woman says to the LPN/LVN, 'My baby is coming! My baby is coming!' She was last checked 15 minutes ago and was 5 cm dilated. What should the LPN/LVN do initially?
- A. Have her checked to see if she has progressed
- B. Reassure her that she cannot be that far along
- C. Reposition her to begin pushing
- D. Request medication to help her relax
Correct Answer: A
Rationale: Urgent reports of delivery sensation require immediate cervical check to confirm progression, as rapid labor can occur, ensuring timely intervention.
The nurse notes dark red blood and a few clots in the catheter of a client two days after a transurethral prostatectomy (TURP). The nurse should first:
- A. Prepare the client for a return to surgery.
- B. Apply traction to the urethral catheter.
- C. Document the findings as normal.
- D. Decrease the client's oral fluid intake.
Correct Answer: B
Rationale: The appearance of dark red blood with a few clots indicates a venous bleed. Traction to the urethral catheter and increasing the client's fluid intake should be tried first before calling the doctor. Answer A would be indicated for the client with an arterial bleed, which is characterized by the appearance of bright red blood and many clots in the catheter, so it is incorrect.
The nurse is caring for an adult who is taking digoxin (Lanoxin) 0.25 mg daily. Which comment by the client is of greatest concern to the nurse because the client is taking digoxin?
- A. I don't seem to have much of an appetite lately.'
- B. My energy level is not as high as it once was.'
- C. My pulse yesterday was 60.'
- D. I have a pain in my right foot.'
Correct Answer: C
Rationale: A pulse of 60 may indicate bradycardia, a potential sign of digoxin toxicity, requiring immediate assessment. Anorexia and fatigue are less specific, and foot pain is unrelated to digoxin.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who is receiving ipratropium (Atrovent) via inhaler. Which of the following symptoms should the nurse report immediately?
- A. Dry mouth
- B. Blurred vision and eye pain
- C. Occasional cough
- D. Mild nasal congestion
Correct Answer: B
Rationale: Blurred vision and eye pain suggest acute angle-closure glaucoma, a rare but serious ipratropium side effect. Options A, C, and D are less urgent: dry mouth is common, cough is expected, and congestion is nonspecific.
The nurse is caring for a client who has a cervical radioactive implant. Which action is not appropriate for the nurse when caring for this client?
- A. Post a radioactive symbol on the client's chart and on the door to the room.
- B. Put on gloves to remove any radioactive implant that may have come out.
- C. Wash hands with soap and water after caring for the client.
- D. Limit the amount of time with the client.
Correct Answer: B
Rationale: Removing a radioactive implant requires specialized handling, not just gloves, to avoid exposure, making this action inappropriate.