Nokea
The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?
- A. Assist the client to a sitting position at the edge of the bed.
- B. Have the client march in place for 30 seconds.
- C. Have the client raise his arms above his head.
- D. Ask the client the last time he fell.
Correct Answer: A
Rationale: The client should be assisted to a sitting position prior to standing. This action can prevent orthostatic hypotension. Marching in place and raising the client's arms above his head are not necessary prior to ambulation. While knowing about the client's last fall can be important, it is not the priority action before ambulating the client.
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A nurse is assessing a patient in the ICU. The patient has the following signs: weak pulse, quick respiration, acetone breath, and nausea. Which of the following conditions is most likely occurring?
- A. Hypoglycemic patient
- B. Hyperglycemic patient
- C. Cardiac arrest
- D. End-stage renal failure
Correct Answer: B
Rationale: All of the clinical signs indicate a hyperglycemic condition.
The LPN is observing a client using crutches for a leg injury. Which of these would indicate a need for more education?
- A. The client places the top padding 1-2 inches below the axilla with a firm grip on the handles.
- B. The client rests the axilla on the top padding and loosely grips the handles with hands.
- C. The client has a slight bend in the elbow when using the handles.
- D. When going down the stairs, the client leads with the injured leg.
Correct Answer: B
Rationale: Resting the axilla on the top of the crutch can cause nerve damage and the client should have a firm grip on the handles.
The death of a beloved spouse places the surviving partner in which type of crisis?
- A. maturational
- B. reactive
- C. nonreactive
- D. situational
Correct Answer: D
Rationale: A situational crisis is an unexpected, unplanned event, such as the death of a spouse. Option 1 is a normal maturational crisis; Choices 2 and 3 are not recognized crisis states.
A 15 year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?
- A. Lab values of Potassium and Sodium
- B. Lab values of glucose and hemoglobin
- C. ECG
- D. CT scan
Correct Answer: A
Rationale: Diuretics can disturb the sodium and potassium balance, resulting in cardiac complications. Monitoring electrolyte levels is critical.
At what point in the nurse-client relationship should termination first be addressed?
- A. in the working phase
- B. in the termination phase
- C. in the orientation phase
- D. when the client initially brings up the topic
Correct Answer: C
Rationale: The client has a right to know the parameters of the nurse-client relationship. If the relationship is to be time limited, the client should be informed of the number of sessions. If it is open-ended, the termination date is not known at the outset, and the client should know that this is an issue that is negotiated at a later date.