Nokea
The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the clients Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially?
- A. Immediately lower the bag and speak privately to unlicensed assistive personnel (UAP)
- B. Let UAP complete assigned tasks and speak to them at the end of the shift
- C. Praise UAP for encouraging the client to walk the entire hallway
- D. Speak with the nurse manager about the need for UAP inservice education
Correct Answer: A
Rationale: The Foley bag must be kept below bladder level to prevent urine backflow and infection risk. Immediate correction and private education ensure safety and learning without delay.
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The nurse is reviewing teaching with the parents of a child who has tinea capitis (ringworm of the scalp) and is newly prescribed griseofulvin oral suspension and 1% selenium sulfide shampoo. Which statement by the child's parent requires the nurse to intervene?
- A. I will discontinue the griseofulvin once the ringworm stops itching and the scales go away.
- B. I will give the griseofulvin suspension to my child after consumption of high-fat food, like ice cream.
- C. I will monitor my child for increased sensitivity to sunlight while taking griseofulvin.
- D. I will wash my child's scalp a few times per week with the medicated shampoo.
Correct Answer: A
Rationale: Griseofulvin requires a full course (6-8 weeks) to eradicate tinea capitis, even if symptoms resolve, to prevent recurrence. High-fat foods enhance absorption, photosensitivity is a side effect, and shampoo use a few times weekly is appropriate.
A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?
- A. I will arrange for a conference with you and the UAP within the next week
- B. I can assure you that I will look into the matter
- C. I would like for you to approach the UAP about the problem the next time it occurs
- D. I will add this concern to the agenda for the next unit meeting
Correct Answer: C
Rationale: Helping staff manage conflict is part of the manager's role. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible.
The doctor has ordered Lovenox (enoxaparin) 20 mg subcutaneously daily. The medication is available as 60 mg per mL. The nurse should administer:
- A. 0.50 mL
- B. 0.53 mL
- C. 0.33 mL
- D. 0.25 mL
Correct Answer: C
Rationale: Calculate: 20 mg ÷ 60 mg/mL = 0.333 mL, rounded to 0.33 mL for accurate dosing of Lovenox.
A woman who comes in for prenatal care has a history of herpes with outbreaks that occur every six months to a year. She asks if this means she will have a cesarean delivery. How should the nurse respond?
- A. If you have active lesions when you go into labor, you will need a cesarean section.'
- B. Cesarean delivery is the only way to protect your baby from herpes.'
- C. Cesarean delivery is no longer recommended for persons with herpes.'
- D. Your obstetrician will decide at the time of delivery which is best for you.'
Correct Answer: A
Rationale: Active herpes lesions at labor necessitate a cesarean to prevent neonatal herpes transmission; otherwise, vaginal delivery may be possible.
Clients taking lithium must be particularly sure to maintain adequate intake of which of these elements?
- A. Potassium
- B. Sodium
- C. Chloride
- D. Calcium
Correct Answer: B
Rationale: Clients taking lithium need to maintain an adequate intake of sodium. Serum lithium concentrations may increase in the presence of conditions that cause sodium loss.