Nokea
The charge nurse is making an assignment for an LPN on an upcoming shift. Which assignment would be appropriate?
- A. a client with a recent head injury and active seizures
- B. a post-operative patient requiring vital sign monitoring every hour
- C. a post-operative patient receiving a blood transfusion
- D. a client with diabetes requiring discharge instruction on insulin injection
Correct Answer: B
Rationale: Vital sign monitoring is within the LPN’s scope. Seizure management, blood transfusions, and discharge teaching require RN expertise.
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During the nurse's assessment of a client who has been diagnosed with anorexia nervosa, the nurse evaluates certain characteristics that accompany an intense fear of gaining weight. What characteristics are most applicable? Select all that apply.
- A. fatigue
- B. excessive exercise regime
- C. normal weight
- D. high blood pressure
Correct Answer: A,B
Rationale: Fatigue and excessive exercise are common in anorexia nervosa due to malnutrition and compulsive behaviors. Normal weight or high blood pressure are less typical.
The nurse performs an assessment of an 8-year-old girl diagnosed with scoliosis. Which of the following observations are expected with scoliosis?
- A. The girl’s thoracic area is asymmetrical.
- B. The girl walks with a waddling gait.
- C. The girl’s lower legs are edematous.
- D. The girl has a protruding sternum.
Correct Answer: A
Rationale: thoracic area becomes noticeably distorted
The nurse is working on a discharge teaching plan for a client prescribed phenelzine (Nardil), a monoamine oxidase inhibitor (MAOI drug). The nurse knows teaching was successful if the client states,
- A. I will not be able to have wine and aged cheese anymore.'
- B. I should avoid all dairy products from now on.'
- C. Taking this medication with vitamin K-containing foods is dangerous.'
- D. I will need to decrease my dietary fiber now.'
Correct Answer: A
Rationale: MAOIs like phenelzine require avoiding tyramine-rich foods (e.g., wine, aged cheese) to prevent hypertensive crisis. Dairy, vitamin K, and fiber are not contraindicated.
A postoperative client whose oxygen saturation has been stable at 96% to 98% suddenly shows a drop to 80%. What initial response is most indicated?
- A. Notify physician.
- B. Administer oxygen.
- C. Assess client and reposition pulse oximeter.
- D. Collect an arterial specimen for ABGs.
Correct Answer: C
Rationale: Assessing and repositioning the pulse oximeter (C) checks for false readings first. Oxygen (B), notifying physician (A), or ABGs (D) follow if needed.
The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?
- A. Notifying the physician
- B. Performing tracheal suctioning
- C. Repositioning the client to the left side
- D. Rechecking the client's O2 saturation
Correct Answer: B
Rationale: Restlessness, tachypnea, and low O2 saturation suggest airway obstruction or secretions. Tracheal suctioning is the initial action to clear the airway and improve oxygenation.