An RN is in charge of a team on a medical/surgical unit that includes an LPN. The RN understands that which of the following is an activity that falls outside the scope of practice of an LPN?
- A. administer oral medications to a client
- B. insert a nasogastric tube
- C. care for a patient with a tracheostomy
- D. develop a nursing care plan
Correct Answer: D
Rationale: Developing a nursing care plan requires assessment and critical thinking, which are RN responsibilities. LPNs can perform the other tasks within their scope.
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When determining whether or not a client is a candidate for restraints, which of the following would be considered an appropriate reason for a restraint?
- A. Current dangerous behavior
- B. History of falls
- C. Recent violent attack on a staff member
- D. Refusal to cooperate with treatment
Correct Answer: A
Rationale: Restraints are justified for current dangerous behavior (A) posing immediate risk to self or others. History of falls (B), past violence (C), or non-cooperation (D) do not warrant restraints.
Which of the following statements by a client with a seizure disorder who is taking topiramate (Topamax) indicates that the client has understood the nurse's instruction?
- A. I will take the medicine before going to bed.
- B. I will drink 8 to 10 ten-ounce glasses of water a day.
- C. I will eat plenty of fresh fruits.
- D. I must take the medicine with a meal or snack.
Correct Answer: B
Rationale: Topiramate increases the risk of kidney stones, so adequate hydration (8-10 glasses of water daily) is essential to prevent this complication.
The nurse is teaching a client with a new diagnosis of glaucoma about eye drop administration. Which of the following instructions should the nurse include?
- A. Apply pressure to the inner canthus after instilling drops.
- B. Instill the drops directly onto the cornea.
- C. Shake the bottle vigorously before use.
- D. Store the drops in the refrigerator.
Correct Answer: A
Rationale: applying pressure to the inner canthus (nasolacrimal occlusion) prevents systemic absorption of the medication
The client admitted with angina is given a prescription for nitroglycerine. The client should be instructed to:
- A. Replenish his supply every 3 months
- B. Take one every 15 minutes if pain occurs
- C. Leave the medication in the brown bottle
- D. Crush the medication and take with water
Correct Answer: C
Rationale: Nitroglycerin should be stored in its original brown bottle to protect it from light and maintain potency.
A nurse assessing a client charts his blood pressure as 134/86. The pulse pressure would be
- A. 48
- B. 86
- C. 220
- D. 96
Correct Answer: A
Rationale: Pulse pressure is calculated as systolic BP minus diastolic BP: 134 - 86 = 48 mmHg.
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