Nokea
The LPN is preparing to clean a client's PEG tube. Which of the following tasks should the nurse perform? A. Gently remove crusty drainage from the site. B. Pull the tube in multiple directions to ensure it is secure. C. Thoroughly dry the skin around the tube site with a clean towel. D. Use mild soap to clean around the tube site. E. Apply talcum powder to the tube site.
- A. B, D, E
- B. A, B, C
- C. A, C, D
- D. C, D, E
Correct Answer: C
Rationale: LPNs caring for the PEG tube should be careful to not disrupt the tube, pull on the tube, or apply any ointment or powder near or on the tube. Talcum powder may irritate the stoma.
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Which of the following is least relevant when reviewing the client's risk for elimination impairment?
- A. current medications
- B. ambulation abilities
- C. family history
- D. hydration status
Correct Answer: C
Rationale: The client's family history is least relevant when determining the risk for elimination impairment.
The nurse provides a postoperative client with an analgesic medication and darkens the room before the client goes to sleep for the night. The nurse's actions:
- A. help the client's circadian rhythm.
- B. stimulate hormonal changes in the brain.
- C. decrease stimuli from the cerebral cortex.
- D. alert the hypothalamus in the brain.
Correct Answer: C
Rationale: Reduction of environmental stimuli (particularly light and noise) from the cerebral cortex (which can be an area of arousal) facilitates sleep. Sleep occurs when there is a decreased input into this area.
To remove hard contact lenses from an unresponsive client, the nurse should:
- A. gently irrigate the eye with an irrigating solution from the inner canthus outward.
- B. grasp the lens with a gentle pinching motion.
- C. don sterile gloves before attempting the procedure.
- D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.
Correct Answer: D
Rationale: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present.
A client's postoperative pain seems to be getting worse instead of better. When the nurse asks the client, 'Why do you think it's getting worse?' the client replies, 'My wife died last month. It's all I can think about.' The nurse must now consider:
- A. calling the physician for an increased dosage of pain medication
- B. calling the physician for a sedative
- C. referring the client for a psychiatric consult
- D. developing interventions for grief and loss
Correct Answer: D
Rationale: The client's grief over his wife's death is likely exacerbating his pain perception, requiring grief and loss interventions to address the affective component.
The nurse is teaching the client, who is 24 hours post abdominal surgery, how to use an IS. Which instructions should the nurse include in the teaching? Select all that apply.
- A. Inhale slowly and deeply through mouth
- B. Seal lips tightly around mouthpiece
- C. After inhaling, hold breath for 2 to 3 seconds
- D. Sit with the HOB down and bed almost flat
- E. Splint the incision with pillows
- F. Exhale forcefully, fast, and hard
Correct Answer: A,B,C,E
Rationale: A: Deep inhalation maximizes alveolar inflation. B: Sealing prevents air leaks. C: Holding breath enhances lung expansion. E: Splinting reduces pain, aiding inhalation. D: High Fowler's position is optimal. F: Slow exhalation prevents hyperventilation.