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During a neurologic examination, which assessment should a nurse perform to test a client's balance?
- A. Romberg test
- B. Heel-to-toe walk
- C. Snellen test
- D. Spinal accessory function
Correct Answer: A
Rationale: The Romberg test is used to assess a client's balance by evaluating their ability to maintain a steady posture with eyes closed. The heel-to-toe walk is another assessment that tests balance by assessing gait and coordination. The Snellen test is used to assess visual acuity and is unrelated to balance. Testing spinal accessory function involves assessing the movement of the head and shoulders and is not directly related to balance assessment.
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A client with diabetes mellitus is being taught by a nurse about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should roll the NPH vial between my hands before drawing it up.
- B. I should draw up the NPH insulin before the regular insulin.
- C. I should inject air into the vial of regular insulin first.
- D. I should wait 10 minutes after mixing the insulin to inject it.
Correct Answer: A
Rationale: The correct answer is A. Rolling the NPH vial between the hands before drawing it up ensures proper mixing of the insulin. Choice B is incorrect because regular insulin should be drawn up first to avoid contamination. Choice C is incorrect as injecting air into the vial of regular insulin is not necessary. Choice D is incorrect as there is no need to wait 10 minutes after mixing the insulin before injecting it.
A patient's neighbor is scheduled for elective surgery. The neighbor's provider indicated that a moderate amount of blood loss is expected during the surgery, and the neighbor is anxious about acquiring an infection from a blood transfusion. Which of the following is appropriate for the nurse to suggest?
- A. Avoid the blood transfusion
- B. Donate autologous blood before the surgery
- C. Use a blood substitute
- D. Take antibiotics before the surgery
Correct Answer: B
Rationale: Donating autologous blood before surgery is an appropriate suggestion by the nurse. This process involves the patient donating their own blood before the surgery, which reduces the risk of infection from transfusions as the patient is receiving their own blood. Choice A is incorrect as avoiding the blood transfusion may not be feasible or safe in the context of expected blood loss during surgery. Choice C is not a common practice and may carry its own risks. Choice D is not directly related to reducing the risk of infection from a blood transfusion.
A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since timed-release capsules are not available at the time of discharge, which dosing schedule should the LPN advise the client to follow?
- A. 9 a.m., 1 p.m., and 5 p.m.
- B. 8 a.m., 4 p.m., and midnight.
- C. Before breakfast, before lunch, and before dinner.
- D. With breakfast, with lunch, and with dinner.
Correct Answer: B
Rationale: The correct dosing schedule for the client to follow is to take the medication at 8 a.m., 4 p.m., and midnight. This timing spaces the doses evenly over the waking hours, ensuring consistent therapeutic levels of the medication. Choice A (9 a.m., 1 p.m., and 5 p.m.) does not evenly distribute the doses throughout the day. Choices C (Before breakfast, before lunch, and before dinner) and D (With breakfast, with lunch, and with dinner) do not provide the required frequency of dosing needed for optimal therapeutic effect.
The healthcare professional is caring for a client who is post-operative following a hip replacement. Which assessment finding would require immediate intervention?
- A. Pain at the surgical site
- B. Swelling in the affected leg
- C. Elevated temperature
- D. Shortness of breath
Correct Answer: D
Rationale: Shortness of breath is a critical assessment finding that could indicate a pulmonary embolism or other serious complication related to surgery, such as a respiratory issue or cardiac problem. Immediate intervention is necessary to prevent further complications or harm to the client. Pain at the surgical site is common post-operatively and can be managed with appropriate pain relief measures. Swelling in the affected leg is expected after a hip replacement and can often be managed conservatively or monitored closely. An elevated temperature could be a sign of infection, which is important to address but may not require immediate intervention unless other symptoms of sepsis are present.
A client with type 1 diabetes mellitus is experiencing hypoglycemia. What is the best initial action for the LPN/LVN to take?
- A. Administer glucagon intramuscularly.
- B. Give the client 4 ounces of orange juice.
- C. Give the client a snack containing protein and carbohydrates.
- D. Encourage the client to rest until symptoms resolve.
Correct Answer: B
Rationale: The best initial action for a client with type 1 diabetes mellitus experiencing hypoglycemia is to give them 4 ounces of orange juice. Orange juice quickly raises blood glucose levels in a hypoglycemic client. Administering glucagon intramuscularly is not the best initial action for hypoglycemia; it is usually reserved for severe hypoglycemia cases. Giving a snack containing protein and carbohydrates is not as rapid as orange juice in raising blood glucose levels during hypoglycemia. Encouraging the client to rest until symptoms resolve does not address the immediate need to raise blood glucose levels in a hypoglycemic state.