Nokea
For care of a patient who has oral cancer, which task would be appropriate to delegate to the LPN/LVN?
- A. Assist the patient to brush and floss.
- B. Give antacids and sucralfate suspension as ordered.
- C. Recommend saliva substitutes.
- D. Explain when brushing and flossing are contraindicated.
Correct Answer: A
Rationale: Assisting with oral hygiene is within the scope of practice for LPNs/LVNs, while medication administration and patient education require higher-level training.
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The nurse is reviewing the laboratory results for a preoperative patient. Which test result should be brought to the attention of the surgeon immediately?
- A. Serum K+ of 3.8 mEq/L
- B. Hemoglobin of 15 g/dL
- C. Blood glucose of 100 mg/dL
- D. White blood cell (WBC) count of 18,500/µL
Correct Answer: D
Rationale: An elevated WBC count indicates potential infection, requiring immediate attention.
What complication can result from tracheal suctioning?
- A. Acute hypoxemia
- B. Gastric dilatation
- C. Hypervolemic shock
- D. Epiglottitis
Correct Answer: A
Rationale: Suctioning temporarily reduces oxygen levels, necessitating careful monitoring.
The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that:
- A. The client should remain on bed rest in a semi-Fowler's position.
- B. The client should alternate ambulation with bed rest with legs elevated.
- C. The client may ambulate and sit in chair as tolerated.
- D. The client may ambulate as tolerated and remain in semi-Fowlers positioning bed.
Correct Answer: D
Rationale: Semi-Fowler's position aids in breathing and reduces pressure on the abdomen.
While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?
- A. Obtain a cardiology consult.
- B. Suction the client less frequently.
- C. Administer an antidysrhythmic medication.
- D. Perform pre-oxygenation prior to suctioning.
Correct Answer: D
Rationale: The correct answer is D: Perform pre-oxygenation prior to suctioning. In this scenario, the increase in heart rate and irregularity could be due to hypoxia resulting from suctioning. Pre-oxygenation helps to ensure adequate oxygenation before the procedure, preventing hypoxia-induced dysrhythmias. By providing oxygen before suctioning, the nurse can minimize the risk of further complications.
Choice A (Obtain a cardiology consult) is incorrect because immediate action is required to address the potential hypoxia, which can be managed by pre-oxygenation.
Choice B (Suction the client less frequently) is incorrect as it does not address the immediate concern of potential hypoxia leading to dysrhythmias.
Choice C (Administer an antidysrhythmic medication) is incorrect as it is not the initial intervention needed in this situation; addressing the underlying cause of potential hypoxia is essential before considering antidysrhythmic medications.
What type of shock is the client experiencing if there is no urine return after inserting a Foley catheter?
- A. Decreased blood pressure
- B. Increased heart rate
- C. Fluid retention
- D. Muscle cramps
Correct Answer: A
Rationale: Decreased blood pressure is a primary symptom in fluid imbalance as a result of inadequate circulating volume, leading to hypotension and possible shock.