Nokea
Palpation of the skin provides the nurse useful information regarding:
- A. Bruising of the skin.
- B. Color of the skin.
- C. Hair distribution.
- D. Turgor of the skin.
Correct Answer: D
Rationale: Palpation assesses skin turgor, indicating hydration status. Bruising and color are visually assessed, and hair distribution is observed, not palpated.
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The nurse receives a prescription from the primary healthcare provider (PHCP) for metoprolol 5 mL intravenous (IV) push x 1 dose. The nurse should take which priority action before administering the medication?
- A. Clarify the prescription with the primary healthcare provider (PHCP)
- B. Assess vital signs
- C. Review the prescription with the pharmacist
- D. Assess the client's allergies
Correct Answer: A
Rationale: Metoprolol IV push prescriptions require clarification to ensure correct dosage and administration rate.
The nurse is assigning clients for the evening shift. Which of the following clients are appropriate for the nurse to assign to a licensed practical nurse to provide client care? Select all that apply.
- A. A client with Crohn's disease who is receiving total parenteral nutrition (TPN).
- B. A client who underwent inguinal hernia repair surgery 3 hours ago.
- C. A client with an intestinal obstruction who needs a Cantor tube inserted.
- D. A client with diverticulitis who needs teaching about his take-home medications.
- E. A client who is experiencing an exacerbation of his ulcerative colitis.
Correct Answer: B,D
Rationale: Licensed practical nurses (LPNs) can provide care for stable clients with predictable outcomes, such as a client post-inguinal hernia repair (B) or a client with diverticulitis needing medication teaching (D). Clients requiring TPN monitoring (A), Cantor tube insertion (C), or managing an acute exacerbation of ulcerative colitis (E) require more complex assessments or interventions typically performed by a registered nurse. CN: Management of care; CL: Synthesize
A client with a recent amputation reports phantom limb pain. Which intervention should the nurse implement first?
- A. Administer prescribed gabapentin.
- B. Apply a cold pack to the stump.
- C. Distract the client with music.
- D. Explain the nature of phantom pain.
Correct Answer: D
Rationale: Explaining phantom pain validates the client's experience, addressing anxiety before other interventions.
A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative teaching, the nurse is reinforcing information about the surgical procedure. Which of the following explanations is most accurate?
- A. The procedure will result in enlargement of the pyloric sphincter.
- B. The procedure will result in anastomosis of the gastric stump to the jejunum.
- C. The procedure will result in removal of the duodenum.
- D. The procedure will result in repositioning of the vagus nerve.
Correct Answer: B
Rationale: The Billroth II procedure involves anastomosis of the gastric stump to the jejunum, bypassing the duodenum. The other options are incorrect descriptions of the procedure.
Which instructions should the nurse include when developing a teaching plan for a client being discharged from the hospital on anticoagulant therapy after having deep vein thrombosis (DVT)? Select all that apply.
- A. Checking urine for bright blood and a dark smoky color
- B. Daily walking as a good exercise
- C. Using garlic and ginger, which may decrease bleeding time
- D. Performing foot/leg exercises and walking around the airplane cabin on long flights
- E. Prevention as the best treatment for DVT
- F. Avoiding surface bumps because the skin is prone to injury
Correct Answer: A,B,D,F
Rationale: Rationales: A) Monitoring urine for bleeding is essential on anticoagulants. B) Daily walking promotes circulation, preventing DVT recurrence. D) Foot/leg exercises and movement during flights reduce stasis. F) Avoiding bumps prevents bruising/bleeding due to anticoagulant therapy. C) Garlic and ginger may increase bleeding risk, not decrease it. E) Prevention is vague and not a specific instruction.