Nokea
Nurse delegating ambulation of client who had knee arthroplasty 5 days ago to an AP. Which of following info should nurse share with the AP? (Select all that apply.)
- A. The roommate is up independently
- B. Client ambulates with his slippers on over his antiembolic stockings
- C. Client uses front-wheeled walker when ambulating
- D. Client had pain med 30 min ago
- E. Client is allergic to codeine
- F. Client ate 50% of his breakfast this morning
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. The nurse should share that the client ambulates with slippers over antiembolic stockings (B) to ensure safety. The nurse should inform that the client uses a front-wheeled walker (C) to maintain stability during ambulation post-knee arthroplasty. Lastly, sharing that the client had pain medication 30 minutes ago (D) is crucial for the AP to monitor for potential side effects and adjust care accordingly.
Incorrect choices:
A: The roommate being up independently is irrelevant to the client's ambulation post-knee arthroplasty.
E: The client's allergy to codeine is important medical information but not essential for the AP to know when delegating ambulation.
F: The client's breakfast intake is not directly related to safe ambulation post-knee arthroplasty.
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RN is making assignments for client care to LPN at beginning of shift. Which of following assignments should LPN question?
- A. Assisting a client who is 24h post-op to use incentive spirometer
- B. Collecting clean-catch urine specimen from client who was admitted on previous shift
- C. Providing nasopharyngeal suctioning for client with pneumonia
- D. Replacing cartridge & tubing on PCA pump
Correct Answer: D
Rationale: The correct answer is D: Replacing cartridge & tubing on PCA pump. This is the assignment the LPN should question. The rationale is that LPNs are not typically trained to handle complex medical devices like PCA pumps, which deliver controlled doses of pain medication. LPNs should question this task as it involves intricate technical skills and potential risks if done incorrectly.
A: Assisting a client with an incentive spirometer is within an LPN's scope of practice and does not require specialized training.
B: Collecting a clean-catch urine specimen is a routine task that LPNs are typically trained to perform.
C: Providing nasopharyngeal suctioning for a client with pneumonia is a common nursing intervention that LPNs are qualified to carry out.
In summary, LPNs should question assignments that are outside their scope of practice or involve technical procedures beyond their training to ensure safe and effective care for the clients.
Nurse providing discharge instructions to client with prescription for oxygen use in home. Which should nurse teach about using oxygen safely in his home? (Select all that apply.)
- A. Family members who smoke must be at least 10 ft from client when his oxygen is on
- B. Nail polish shouldn't be used near client receiving oxygen
- C. A 'No Smoking' sign should be placed on front door
- D. Cotton bedding/clothing should be replaced with items made from wool
- E. Fire extinguisher should be readily available in home
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
B: Nail polish contains flammable substances, which can pose a fire hazard near oxygen. Teaching the client to avoid using nail polish near oxygen is essential for safety.
C: Placing a 'No Smoking' sign on the front door serves as a clear reminder to visitors and family members about the importance of not smoking near the client using oxygen.
E: Having a fire extinguisher readily available in the home is crucial in case of a fire emergency, especially when oxygen is being used, as oxygen can accelerate combustion.
Incorrect Choices:
A: While it is important for family members who smoke to stay away from the client when oxygen is on, the 10 ft rule is arbitrary and not evidence-based.
D: There is no significant safety benefit in replacing cotton bedding/clothing with items made from wool regarding oxygen use in the home.
Summary: Teaching about avoiding flammable substances like nail polish, displaying a 'No Smoking' sign,
Occupational health nurse is caring for employee with chemical burn from unknown chemical. Which intervention should nurse include in care plan?
- A. Irrigate affected area with running water
- B. Wash affected area with antibacterial soap
- C. Brush chemical off skin & clothing
- D. Apply neutralizing agent
Correct Answer: C
Rationale: The correct answer is C: Brush chemical off skin & clothing. This intervention is crucial to prevent further exposure and damage from the unknown chemical. By brushing off the chemical, the nurse can minimize the contact time and reduce the risk of more severe burns. Irrigating with water (choice A) may spread the chemical or react with it, worsening the burn. Washing with antibacterial soap (choice B) can also react with the chemical and cause more harm. Applying a neutralizing agent (choice D) can potentially worsen the burn if the wrong agent is used. Therefore, choice C is the best initial intervention to prevent further harm.
Nurse is caring for client who is 24h post-op following abdominal surgery. Nurse suspects client's pain management is inadequate. Which of following data reinforce suspicion? (Select all that apply.)
- A. Client seems easily agitated
- B. Client is nonadherent with coughing, deep breathing, dangling
- C. Client may have pain med every 4-6h but accepts it every 6-7h
- D. Client reports tenderness in his right lower leg
- E. Client's vital signs are heart rate 110/min, respiratory rate 20/min, temp 37C, BP 136/80 mmHg
Correct Answer: B, C, E
Rationale: The correct answers are B, C, and E. Choice B indicates client's nonadherence to post-op respiratory exercises may lead to inadequate pain management. Choice C shows client not taking pain meds as prescribed, suggesting inadequate pain relief. Choice E reveals elevated heart rate and BP, indicating physiological stress from pain. Choices A and D do not directly relate to pain management. Choice A may be due to discomfort but not necessarily indicative of inadequate pain management. Choice D's leg tenderness is not directly linked to post-op pain.
Nurse evaluating how well client learned the info presented in teaching about heart-healthy diet. Client states she understands what to do now. Which actions by nurse should assist evaluation of client's learning?
- A. Encourage client to ask questions
- B. Ask client to explain how to select or prepare meals
- C. Encourage client to fill out eval form
- D. Ask client if she has resources for further instruction on topic
Correct Answer: B
Rationale: The correct answer is B: Ask client to explain how to select or prepare meals. This action allows the nurse to assess the client's understanding by evaluating if the client can articulate the key concepts of a heart-healthy diet, demonstrating comprehension. It goes beyond a simple affirmation of understanding and requires the client to apply the knowledge. Encouraging questions (choice A) is important but may not provide a direct assessment of the client's grasp of the material. Choices C and D do not directly assess the client's understanding of the heart-healthy diet teachings.