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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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A 2-year-old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect?
- A. Black, sticky stools
- B. Greasy, foul-smelling stools
- C. Stools mixed with blood and mucus
- D. Thin, 'ribbon-like' stools
Correct Answer: C
Rationale: Intussusception causes intestinal obstruction, often leading to 'currant jelly' stools (blood and mucus). Black, sticky stools suggest upper GI bleeding. Greasy stools indicate malabsorption. Ribbon-like stools suggest rectal narrowing.
The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply.
- A. Avoid intake of dairy products
- B. Drink large amounts of fluid with meals
- C. Eat several small meals each day
- D. Eliminate fried, fatty foods
- E. Lie down on the left side after meals
Correct Answer: C,D
Rationale: Small, frequent meals reduce stomach acid reflux, and avoiding fatty foods decreases acid production. Dairy can neutralize acid, large fluid intake with meals distends the stomach, and lying down post-meal worsens reflux.
The nurse is preparing to administer ear drops to an adult client. It would require follow-up if the nurse
- A. instills the ear drops at room temperature
- B. instills the ear drops by placing the dropper into the ear canal
- C. pulls the pinna of the client's ear up and back before instillation
- D. places a cotton ball loosely in the outermost auditory canal after instillation
Correct Answer: B
Rationale: Placing the dropper into the ear canal risks injury and contamination. Ear drops should be instilled by holding the dropper above the canal. Other actions are correct: room-temperature drops prevent discomfort, pulling the pinna straightens the canal, and a cotton ball retains the medication.
Laboratory Reference Ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?
- A. 9 year-old crying with pain and swelling of the left ankle after a popping sound while playing soccer
- B. 29-year-old with neck swelling and increased pain 2 days after thyroidectomy
- C. 43-year-old with blood glucose of 423 mg/dL (23.5 mmol/L), dehydration, and trace ketones in urine
- D. 72-year-old who is incontinent with acute altered mental status and is yelling at staff
Correct Answer: B
Rationale: Neck swelling and pain post-thyroidectomy suggest possible hematoma or airway compromise, a life-threatening emergency requiring immediate assessment. Other conditions, while serious, are less immediately critical.
The nurse is reinforcing teaching about how to use a metered-dose inhaler to a 9-year-old with asthma. Place the nurse's instructions in the appropriate order. All options must be used.
- A. Exhale completely
- B. Deliver one puff of medication into spacer
- C. Place lips tightly around the mouth piece
- D. Rinse mouth with water
- E. Shake the inhaler and attach it to spacer
- F. Take a slow deep breath, and hold it for 10 seconds
Correct Answer: E,A,B,C,F,D
Rationale: The correct order is: 1) Shake the inhaler and attach it to spacer (prepares medication); 2) Exhale completely (clears lungs); 3) Deliver one puff into spacer (releases medication); 4) Place lips tightly around the mouthpiece (ensures delivery); 5) Take a slow deep breath, and hold it for 10 seconds (allows medication absorption); 6) Rinse mouth with water (prevents oral thrush).