Nokea
The LPN is caring for a 32-year-old female client who is 8 hours post-op after a tonsillectomy. Which of these would be an appropriate action taken by the nurse?
- A. Inform the client that ear pain may occur and is normal.
- B. Provide ice water and a straw to promote easy fluid consumption.
- C. Provide hot tea to soothe the throat.
- D. Monitor vitals every 15 minutes.
Correct Answer: A
Rationale: Referred pain in the ear is normal after a tonsillectomy because of related nerve pathways. Vitals should be monitored every 15 minutes in the immediate postoperative period and then every 4 hours thereafter. Straws and hot beverages should be avoided as they may irritate the throat and disturb healing.
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The nurse is observing the UAP prepare a shower for the client who requires assistance with ambulation and hygiene. Which action(s) by the UAP indicate understanding of the procedure? Select all that apply.
- A. Sets the water temperature at 100° to 105° F (37° to 40° C).
- B. Locks the door to provide the client with privacy.
- C. Uses a chair for the client to sit on in the shower.
- D. Ensures a nonskid surface is in the shower.
- E. Helps to wash areas the client cannot reach.
Correct Answer: C,D,E
Rationale: C: A shower chair prevents falls for a client with ambulation issues. D: A nonskid surface enhances safety. E: Assisting with hard-to-reach areas supports hygiene. A: Water should be 110°-115°F for comfort. B: Locking the door is unsafe for a client needing assistance.
On first meeting, a new nurse manager makes eye contact, smiles, initiates conversation about the previous work experience of nurses, and encourages active participation by nurses in the dialogue. Her behavior is an example of:
- A. aggressiveness.
- B. passive aggressiveness.
- C. passiveness.
- D. assertiveness.
Correct Answer: D
Rationale: This nurse manager is demonstrating assertive behavior. Aggressive behavior dominates or embarrasses. Passive behavior is nervous or timid. Passive-aggressive behavior is dominating or manipulative without directness.
A client with dysphagia is ready to eat lunch. Which of these foods on the tray would be best to start with when assisting the client?
- A. diced fruit
- B. apple juice with a liquid thickener
- C. Jell-O™
- D. toast
Correct Answer: B
Rationale: A client with dysphagia is at risk for aspiration. A liquid thickener will allow the LPN to assess the client's ability to swallow prior to introducing pureed or solid foods. Since Jell-O™ melts into a clear liquid, it should not be used when assessing swallowing ability.
The experienced nurse and the new nurse are preparing to provide phototherapy to the 4-day-old infant with hyperbilirubinemia. Which information should the experienced nurse include when instructing the new nurse about providing phototherapy for the infant?
- A. Keep the infant fully clothed to prevent chilling and hypothermia.
- B. Cover the infant's eyes with eye shields to prevent retinal damage.
- C. Limit the number of feedings to reduce the number of soiled diapers.
- D. Discontinue the phototherapy if the infant develops a mild skin rash.
Correct Answer: B
Rationale: B: Eye shields protect retinas from phototherapy light. A: Clothing reduces skin exposure, hindering bilirubin conversion. C: Increased feedings aid bilirubin excretion. D: Mild rashes are harmless and don't warrant discontinuation.
The method of splinting is always dictated by:
- A. Location of the injury and whether it is open or closed
- B. The severity of the client's condition and the priority decision
- C. The number of available rescuers and the type of splints
- D. All of the above
Correct Answer: B
Rationale: The severity of the client's condition and priority decision dictate splinting to ensure stabilization and prevent further injury, taking precedence over location or resources.