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An RN is making assignments for client care to an LPN at the beginning of shift. Which of the following assignments should the LPN question?
- A. Assisting a client who is 24h post-op to use incentive spirometer
- B. Collecting clean-catch urine specimen
- C. Providing nasopharyngeal suctioning for pneumonia client
- D. Replacing cartridge & tubing on PCA pump
Correct Answer: D
Rationale: The LPN should question replacing cartridge & tubing on PCA pump (Choice D) because this task involves manipulating the patient's medication delivery system, which is beyond the LPN's scope of practice. LPNs are not trained to handle complex medication administration devices like PCA pumps, as this requires a higher level of knowledge and skill typically reserved for RNs. The LPN should advocate for clarification from the RN or delegate this task to someone with the appropriate training. Choices A, B, and C are within the LPN's scope of practice and do not require specialized training like manipulating a PCA pump.
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Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.)
- A. Client who's dehydrated & receiving IV fluid/electrolytes
- B. Client with NG tube to treat small bowel obstruction
- C. Client who's scheduled for TURP (prostate resection)
- D. Client who is 24h post-op after mastectomy
- E. Client scheduled for appendectomy
Correct Answer: C,D
Rationale: The correct answers are C and D.
C: The client scheduled for a TURP (transurethral resection of the prostate) can be safely discharged as this surgery is elective and not urgent.
D: The client who is 24 hours post-op after a mastectomy can also be discharged as they are stable and beyond the immediate post-operative phase.
A: Client receiving IV fluids for dehydration should not be discharged as they require ongoing treatment and monitoring.
B: Client with an NG tube for a small bowel obstruction should not be discharged as they require close observation and treatment.
E: Client scheduled for an appendectomy should not be discharged as this procedure is likely urgent and may require immediate attention.
As part of admission process
- A. nurse at long-term care facility is gathering nutrition history for client with dementia. Which component is priority to determine from their family?
- B. BMI
- C. Usual times for meals/snacks
- D. Favorite foods
- E. Any difficulty swallowing
Correct Answer: D
Rationale: The correct answer is D: Favorite foods. This is because knowing the client's favorite foods is crucial in ensuring they receive proper nutrition and enjoy their meals, especially for someone with dementia who may have difficulty remembering or expressing preferences. It helps enhance their quality of life and promotes adequate food intake.
Other choices are less critical:
A: Nutrition history can include various components, not just family input.
B: BMI is important but not the priority when gathering nutrition information.
C: Knowing meal/snack times is relevant but not as crucial as favorite foods.
E: Swallowing difficulty is important but not the priority in this scenario.
Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I have my own apartment now, but it's not easy living away from my parents
- B. It's been so stressful for me to even think about having my own family
- C. I don't even know who I am yet, & now I'm supposed to know what to do
- D. My girlfriend is pregnant, & I don't think I have what it takes to be a good father
Correct Answer: C
Rationale: The correct answer is C because the young adult expressing uncertainty about their own identity indicates a potential issue with self-awareness and self-esteem, which are foundational for healthy development. This can impact decision-making and overall well-being. Choices A, B, and D focus on external factors (living situation, family stress, and impending fatherhood) that can be addressed once the individual's self-identity is better understood. Prioritizing self-discovery and self-acceptance can lead to more effective coping mechanisms and decision-making skills for handling other stressors.
Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when a new nurse states that a client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke leads to severe dehydration and vasodilation, causing a drop in blood pressure (hypotension). Bradycardia (B), clammy skin (C), and bradypnea (D) are not characteristic of heat stroke. Bradycardia is a slow heart rate, while heat stroke typically causes tachycardia. Clammy skin is more indicative of shock or hypoglycemia, not heat stroke. Bradypnea is slow breathing, but heat stroke usually leads to rapid, shallow breathing. Therefore, hypotension is the most appropriate choice as it aligns with the physiological response to heat stroke.
Nurse at elementary school is planning health promotion & primary prevention class. Which topics are appropriate for parents of school-age children? (Select all that apply.)
- A. Childhood obesity
- B. Substance use disorders
- C. Scoliosis screening
- D. Front-seat seatbelt use
- E. Stranger awareness
Correct Answer: A,B,C,E
Rationale: The correct topics for parents of school-age children include childhood obesity, substance use disorders, scoliosis screening, and stranger awareness. A: Childhood obesity is relevant for promoting healthy lifestyles. B: Substance use disorders address risks children may face. C: Scoliosis screening is important for early detection. E: Stranger awareness educates on safety. Incorrect choices: D: Front-seat seatbelt use is more child-specific and not a primary concern for parents. F & G: Not provided in the question.