Nokea
An adult male has an IV in the left arm. The client calls the nurse and says that his left arm hurts. The LPN checks the IV site and notes that it is cool and blanched and not running well. What should the LPN do at this time?
- A. Flush the IV with normal saline
- B. Remove the IV immediately and start a new line
- C. Tell the charge nurse that the client's IV appears to be infiltrated
- D. Ask the charge nurse to check to see if the client has phlebitis
Correct Answer: B
Rationale: Cool, blanched skin and poor flow indicate infiltration; removing the IV and starting a new line prevents tissue damage.
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The nurse begins to assist with ambulation of a 9-year-old client who is 1 day postoperative appendectomy when the child cries out, 'It hurts too much. I can't do it.' Which action should the nurse complete first?
- A. Administer a PRN analgesic and monitor for adverse effects
- B. Ask the client to point to a numeric scale to indicate pain level
- C. Come back later in the day to attempt ambulation again
- D. Encourage the client to walk to promote blood circulation
Correct Answer: B
Rationale: Assessing pain level using a numeric scale is the first step to quantify the child's pain and determine the need for analgesics or other interventions. Administering analgesics without assessment is premature, delaying ambulation avoids addressing pain, and encouraging walking ignores the child's distress.
The nurse is assessing a newborn delivered at home by a client addicted to heroin. Which of the following would the nurse expect to observe?
- A. Hypertonic neuro reflex
- B. Immediate CNS depression
- C. Lethargy and sleepiness
- D. Jitteriness at 24-48 hours
Correct Answer: D
Rationale: Jitteriness at 24-48 hours. Withdrawal signs may not be evident for 1-2 days after birth. Irritability and poor feeding also are evident.
In preparing medications for a client with a gastrostomy tube, the nurse should contact the health care provider before administering which of the following drugs through the tube?
- A. Cardizem SR tablet (diltiazem)
- B. Lanoxin liquid
- C. Os-cal tablet (calcium carbonate)
- D. Tylenol liquid (acetaminophen)
Correct Answer: A
Rationale: Cardizem SR is a 'sustained-release' drug form. Sustained release (controlled-release, long-acting) drug formulations are designed to release the drug over an extended period of time. If crushed, as would be required for gastrostomy tube administration, sustained-release properties and blood levels of the drug will be altered. The provider must substitute another medication.
A 72-year-old woman is being treated for pneumonia. Physician's orders include an antibiotic, oxygen PRN for O2 saturation less than 90, and pulse oximetry every 4 hours. The nurse obtains a pulse oximetry reading of 82% on room air. What is the best action for the nurse to take?
- A. Report the finding to the physician
- B. Report the finding to the registered nurse to get instructions
- C. Start supplemental oxygen
- D. Start oxygen and repeat the pulse oximetry in 20 minutes
Correct Answer: C
Rationale: An O2 saturation of 82% requires immediate supplemental oxygen per orders to correct hypoxia, the priority action.
Laboratory Reference Range
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
The nurse has received information from unlicensed assistive personnel about assigned client situations. Which of the following situations should the nurse address first?
- A. Client who has type 1 diabetes mellitus and a fasting capillary blood glucose level of 90 mg/dL (5.0 mmol/L)
- B. client who is collecting a 24-hour urine specimen and discarded the last void by mistake
- C. client who is requesting clarification about the diagnostic procedure that is scheduled to begin in 4 hours
- D. client who was recently admitted to a room that has a full sharps disposal container on the wall
Correct Answer: D
Rationale: A full sharps container poses an immediate safety hazard and must be addressed first. Normal glucose , a discarded void , and procedure clarification are less urgent.