Nokea
The licensed practical nurse (LPN) is collecting data on several clients in the antepartum unit. Which of the following clients should the LPN report to the registered nurse for further assessment?
- A. 24 weeks gestation, 1-hour glucose screen is 120 mg/dL (6.6 mmol/L)
- B. 25 weeks gestation, hemoglobin is 9 g/dL (90 g/L)
- C. 30 weeks gestation, nonstress test is reactive
- D. 36 weeks gestation, WBC count is 13,000/mm^3 (13 x 10^9/L)
Correct Answer: B
Rationale: Hemoglobin of 9 g/dL (B) indicates anemia, requiring further assessment. Normal glucose (A), reactive nonstress test (C), and slightly elevated WBC (D) are less urgent.
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The nurse has taught the parent of a pediatric client who will be receiving growth hormone replacement therapy. Which of the following statements by the parent would require follow-up?
- A. The medication needs to be given at bedtime to be most effective.
- B. My child will achieve a height equal to peers after receiving therapy.
- C. The medication will be discontinued when my child's bone growth ceases.
- D. Routine x-rays may be required during therapy to monitor bone lengthening.
Correct Answer: B
Rationale: Expecting equal height to peers (B) is unrealistic, as outcomes vary. Bedtime dosing (A), discontinuation at bone closure (C), and x-rays (D) are correct.
The wife of a 65 -year-old man says to the clinic nurse, 'I think the doctor should check out my husband's hearing. Either he is totally ignoring me and everyone else or he has a hearing problem.' How is the man likely to respond when the nurse asks him if he has difficulty hearing?
- A. I can hear women better than men.
- B. There's nothing wrong with my hearing. People around me just mumble a lot.
- C. I really need to get my hearing checked.
- D. Why should an old man like me care if he hears or not?
Correct Answer: B
Rationale: People who are losing their hearing usually complain that the people around them mutter. Denial is a very common response to hearing loss. Most older people who are having difficulties with hearing wait years before they will admit to hearing loss and accept treatment. Most older people who are losing their hearing hear lower frequencies (men's voices) better than higher frequencies (women's voices). Answer 4 not only indicates denial, but it also suggests that the client is in despair as opposed to ego integrity.
A client with emphysema visits the clinic. While teaching about proper nutrition, the nurse should emphasize that the client should
- A. Eat foods high in sodium to increase sputum liquefaction
- B. Use oxygen during meals to improve gas exchange
- C. Perform exercise after respiratory therapy to enhance appetite
- D. Cleanse the mouth of dried secretions to reduce risk of infection
Correct Answer: B
Rationale: Use oxygen during meals to improve gas exchange. This supports breathing and energy needs during eating.
A housekeeping employee tells the staff nurse of having a headache and asks for acetaminophen. How should the nurse respond?
- A. Ask about liver disease and give acetaminophen from the nurse's personal supply
- B. Check for allergies to drugs before giving acetaminophen from hospital stock
- C. Check the employee's blood pressure
- D. Refer employee to the employee's health care provider
Correct Answer: D
Rationale: Nurses cannot dispense medications without a prescription (A, B). Checking blood pressure (C) is irrelevant. Referring to a provider (D) ensures proper evaluation and treatment.
The home health nurse is reinforcing teaching for a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement will require further teaching about digoxin?
- A. I will call the health care provider if I don't feel like eating.
- B. I will call the health care provider if I feel dizzy and lightheaded.
- C. I will call the health care provider if I have trouble reading.
- D. I will take my blood pressure before taking my medicine.
Correct Answer: D
Rationale: Taking blood pressure (D) is unrelated to digoxin monitoring. Anorexia (A Anorexia (A), dizziness (B), and visual changes (C) are signs of digoxin toxicity, requiring provider notification.