Nokea
The LPN is placing a Foley in a female client. Place the following steps in the appropriate order.A.Prepare the sterile field., B.Separate labia with non-dominant hand., C.Clean the urinary meatus using cleansing solutions and forceps. D. Inflate catheter balloon. E. Place the client in a supine position with flexed knees. F. Place lubricant on catheter. G. Place catheter in meatus with dominant (sterile) hand
- A. E, A, B, F, G, C, D
- B. A, E, B, F, G, D, C
- C. A, E, F, B, C, G, D
- D. E, A, F, B, C, G, D
Correct Answer: D
Rationale: The LPN should follow the correct order of catheter insertion to ensure the catheter is inserted safely. Any other variant of insertion may cause compromise of sterility and client harm.
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The nurse is assessing the client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding requires immediate intervention by the nurse?
- A. Nasogastric tube to low intermittent suction has small amounts of dark bloody returns.
- B. Oxygen saturation level is 92%, and oxygen by nasal cannula is set at 2 liters.
- C. The incisional dressing has a 25-cent-piece-sized shadow of new drainage.
- D. The Jackson-Pratt drain is round in shape with 30 mL serosanguineous drainage.
Correct Answer: D
Rationale: D: A round JP drain indicates lost suction, requiring immediate emptying and compression. A: Minor bloody NG returns are normal post-surgery. B: 92% saturation is adequate. C: Small drainage is monitorable.
The nurse has completed client teaching about introducing solid foods to an infant. To evaluate teaching, the nurse asks the mother to identify an appropriate first solid food. Which of the following is an appropriate response?
- A. Pureed canned squash
- B. Pureed apples
- C. Yogurt
- D. Infant rice cereal
Correct Answer: D
Rationale: Infant rice cereal is recommended as a first solid food due to its digestibility and added iron, suitable for infants starting solids.
The nurse is using a hypothermia blanket for the febrile client. Which findings should prompt the nurse to consider that the client is hypothermic? Select all that apply.
- A. Increased urine output
- B. Increased drowsiness
- C. Decreased heart rate (HR)
- D. Decreased blood pressure (BP)
- E. Increased core body temperature
Correct Answer: B,C,D
Rationale: B: Drowsiness results from low cardiac output affecting the CNS. C: Decreased HR reflects thermoregulation effects. D: Decreased BP reduces cardiac workload. A: Hypothermia decreases urine output. E: Hypothermia lowers core temperature.
Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct Answer: B
Rationale: Compliance or performance at the minimally acceptable level is not considered quality care.
Nonpharmacological pain management involves all of the following except:
- A. hypnosis alone.
- B. psychological care, including support groups.
- C. physical and psychological modalities.
- D. pain-reducing drugs only.
Correct Answer: D
Rationale: All physical and psychosocial therapies can be used concurrently with drugs and other modalities to manage pain. These interventions can be carried out by the nurse with the client and family.