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The licensed practical nurse is caring for a 1-year old with a history of prematurity. Which developmental finding requires further evaluation by the physician?
- A. The child has been creeping for 3 months.
- B. The child can pull to a standing position.
- C. The child uses a pincer grasp.
- D. The child can sit with support.
Correct Answer: D
Rationale: Sitting with support at 1 year is delayed, especially for a preterm child, and requires evaluation. Creeping , standing , and pincer grasp are age-appropriate.
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The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following actions is the PRIORITY?
- A. Encourage the client to use the incentive spirometer.
- B. Administer pain medication as needed.
- C. Position the client with the legs abducted.
- D. Check the surgical dressing for drainage.
Correct Answer: C
Rationale: Positioning with legs abducted prevents hip dislocation, a critical complication post-hip replacement. Options A, B, and D are important but secondary: incentive spirometry prevents pneumonia, pain management supports recovery, and dressing checks monitor bleeding.
If Ms. Barrett's distance vision is 20/30, which of the following statements is true?
- A. The client can read from 20' what a person with normal vision can read at 30'.
- B. The client can read from 30' what a person with normal vision can read at 20'.
- C. The client can read the entire chart from 30'.
- D. The client can read the chart from 20' with the left eye and from 30' with the right eye.
Correct Answer: A
Rationale: The numerator, which is always 20, is the distance in feet between the chart and the client. The denominator, which ranges from 10 to 200, indicates the distance at which a normal eye can read the chart.
The nurse is caring for a client with a history of deep vein thrombosis.
- A. Which intervention is most important for a client with a deep vein thrombosis?
- B. Administer analgesics for pain relief.
- C. Apply warm, moist compresses to the leg.
- D. Encourage active range-of-motion exercises.
- E. Maintain bed rest with leg elevation.
Correct Answer: D
Rationale: Bed rest with leg elevation reduces venous pressure and prevents clot dislodgement in DVT. Analgesics and compresses are supportive, and active exercises risk embolization.
The nurse is assigned a team with another registered nurse and an LPN.
Which of the following patients should the nurse assign to the LPN?
- A. A 67-year-old man who is NPO and scheduled for a transurethral resection of the prostate (TURP) in 3 hours.
- B. A 53-year-old woman with an IV of 0.9% NaCl at 100 cc/h who had a lumbar laminectomy two days ago.
- C. A 40-year-old woman with a Hemovac drain and a large surgical dressing from a mastectomy 2 days ago who is showing signs of depression.
- D. A 27-year-old woman scheduled for discharge later today after receiving chemotherapy through a portacath for treatment of leukemia.
Correct Answer: B
Rationale: Strategy: The LPN/LVN is assigned stable patients with expected outcomes. (1) needs preoperative teaching and assessment (2) correct-basic care needs can be met by the LPN/LVN, don't make patient assignments based on equipment (3) needs therapeutic intervention, teaching, and assessment (4) needs assessment and teaching
The nurse is caring for a client who is postoperative day 1 after a coronary artery bypass graft (CABG). Which of the following findings should the nurse report immediately?
- A. Heart rate of 90 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Chest tube drainage of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-CABG complication. Options A, C, and D are normal or expected.