Nokea
The LPN is receiving the report on a comatose client at the start of the shift at 1500. What statement should be of most concern?
- A. The client was repositioned on his right side at 1100.
- B. The client was bathed and skin was assessed head-to-toe at 0900 with no abnormal findings.
- C. The client's PEG tube was changed 6 months ago.
- D. The client's indwelling urinary catheter was last changed 5 days ago.
Correct Answer: A
Rationale: Bedridden clients should be repositioned every 2 hours to prevent skin breakdown.
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The nurse is teaching a client about sleep and gives background information on normal sleep patterns. Which of the following substances promotes sleep?
- A. serotonin
- B. cortisone
- C. alcohol
- D. narcotics
Correct Answer: A
Rationale: Serotonin is a substance that is in the body and promotes sleep. Serotonin might play a role in synthesis of a hypnogenic factor that directly causes sleep. Drugs and alcohol can disrupt REM sleep, although they might accelerate the onset of sleep.
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.
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.
The client who has bilateral hand burns reports wearing soft contact lenses that need to be removed. Which action(s) are important for the nurse to include in this procedure? Select all that apply.
- A. Perform hand hygiene and don gloves.
- B. Pinch the lens over the pupil and remove.
- C. Place the lens in a sterile container with normal saline.
- D. Irrigate the eye with normal saline to loosen the lens.
- E. Instruct the client to look up when removing the lens.
Correct Answer: A,C,E
Rationale: A: Hand hygiene and gloves prevent infection. C: Normal saline keeps lenses moist if no lens solution is available. E: Looking up aids safe lens removal. B: Pinching over the pupil risks corneal abrasion. D: Irrigation could damage or lose the lens.
A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO0. How many milliliters of fluid did the patient ingest?
- A. $440 \mathrm{ml}$
- B. $480 \mathrm{ml}$
- C. $22 \mathrm{ml}$
- D. $660 \mathrm{ml$
Correct Answer: B
Rationale: 1 ounce = 30 ml, so Juice, 6 ounces (half of 12 oz) × 30 = 180 ml (Remember that oz is an abbreviation for ounces.) Soup, 4 ounces × 30 = 120 ml JELL-OB, 6 ounces × 30 = 180 ml 180 + 120 + 180 = 480 ml Note that gelatin, ice cream, and other things that are liquid at room temperature are counted as fluids.