Nokea
The LPN needs to determine the client's respiratory rate. What is the best technique to do this?
- A. Tell the client you need to count their respiratory rate.
- B. Subtly watch the client from across the room when they are doing an activity.
- C. Ask the client to sit still for 30 seconds.
- D. Count respirations while pretending to check the client's pulse.
Correct Answer: D
Rationale: The best technique to determine a client's respiratory rate is to count respirations while pretending to check the client's pulse. You should not inform the client that you are counting their respirations, as this might lead to a change in their breathing pattern. Pretending to check the pulse allows you to be close to the client without revealing that you are assessing their respiratory rate. Asking the client to sit still may not be as effective, as it may cause them to concentrate on their breathing. Watching from across the room may not provide an accurate assessment of respirations, as they might be difficult to observe.
You may also like to solve these questions
While assisting with data collection, the client informs the nurse that he is having difficulty swallowing medications and food. The nurse gathers additional subjective data and documents that the client is experiencing which disorder?
- A. Pyrosis
- B. Anorexia
- C. Eructation
- D. Dysphagia
Correct Answer: D
Rationale: The correct answer is 'Dysphagia.' Dysphagia is the term used to indicate difficulty swallowing, which can occur in disorders of the throat or esophagus. Anorexia refers to a loss of appetite, not difficulty swallowing. Eructation is the medical term for belching, not difficulty swallowing. Pyrosis is heartburn, a burning sensation in the esophagus and stomach caused by the reflux of gastric acid, not difficulty swallowing.
When a 25-year-old client complains of chest congestion and cough after previously presenting with cold symptoms, what data should the nurse collect?
- A. Data related to follow-up care
- B. A complete health database
- C. Data related to the respiratory system
- D. Data related to the treatment for the cold
Correct Answer: C
Rationale: In this case, the nurse should collect data related to the respiratory system since the client is presenting with symptoms like chest congestion and cough, indicating a respiratory issue. Focusing on the respiratory system will help gather pertinent information to assess the current problem comprehensively. A complete health database involves a detailed health history and full physical examination, which is beyond the immediate scope of the presenting issue. Data related to follow-up care is premature as the primary focus should be on assessing the current respiratory symptoms. Data related to the treatment for the cold is not the priority at this stage, as understanding the underlying respiratory problem is crucial for appropriate intervention.
During a home visit, the LPN finds a client taking Amiodarone. Which statement by the client indicates an understanding of potential drug side effects?
- A. "It is normal if I have numbing or tingling in my feet."?
- B. "I need to make sure I wear sunblock when going outdoors."?
- C. "I need to take supplemental vitamin B12."?
- D. "I should avoid eating leafy vegetables."?
Correct Answer: B
Rationale: The correct answer is B. Amiodarone can cause increased photosensitivity, making it essential for the client to wear sunblock when exposed to sunlight. Choice A is incorrect because numbing or tingling in the feet is not a common side effect of Amiodarone. Choice C is unrelated as the drug does not typically require supplemental vitamin B12. Choice D is also incorrect as there is no need to avoid leafy vegetables specifically due to Amiodarone.
The client has an order for a 1,000 mL bag of fluids to be infused over 8 hours. What is the correct rate?
- A. 100 mL/hr
- B. 125 mL/min
- C. 125 mL/hr
- D. 80 mL/min
Correct Answer: C
Rationale: To determine the correct infusion rate, divide the total volume of fluids (1,000 mL) by the total infusion time (8 hours), resulting in a rate of 125 mL/hr. This calculation ensures the appropriate administration of fluids over the specified time period. Choice A (100 mL/hr) is incorrect as it does not match the calculated rate based on the given information. Choice B (125 mL/min) is inaccurate because the question specifies the rate in hours, not minutes. Choice D (80 mL/min) is incorrect as it provides the rate in minutes rather than hours, which is the required unit for this scenario.
The nurse is caring for a postpartum woman who has relinquished her baby for adoption. The care plan for the client should include which of the following priority strategies?
- A. Make a referral for grief counseling.
- B. Allow the woman to see her baby initially and respect her wishes for further visits.
- C. Provide opportunities for the woman to express her feelings.
- D. Inform the woman she has the right to change her mind about relinquishment.
Correct Answer: C
Rationale: When caring for a postpartum woman who has relinquished her baby for adoption, it is crucial for the nurse to provide opportunities for the woman to express her feelings. Most women who make this decision have done so with love and pain, and it is essential to allow them to verbalize their emotions, which may include grief, loneliness, and guilt. Referring the woman for grief counseling may be necessary if she lacks a support system or requests help to navigate her grief. Allowing the woman to see her baby is important, and the nurse should respect her wishes regarding visitation as it can aid in the grief process. While the woman does have the right to change her mind about relinquishment until final legal arrangements are made, suggesting this option may inadvertently influence her decision and should be approached cautiously. Therefore, providing emotional support and opportunities for expression are the priority strategies in this situation.