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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: You should not tell the client you are counting their respirations, as this may cause them to alter their breathing pattern. Pretending to check a pulse allows you to get close to the client without cluing them in to what you are assessing. Standing across the room is not the best way to assess for respirations as they may be difficult to see.
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Ciprofloxacin is prescribed for the client to treat a UTI. Which information should the nurse stress when teaching the client about the medication?
- A. Avoid taking ciprofloxacin with dairy products such as milk or yogurt.
- B. Treat diarrhea, a side effect of ciprofloxacin, with bismuth subsalicylate.
- C. Avoid fennel because it will increase the absorption of the ciprofloxacin.
- D. Take dietary calcium tablets one hour before or two hours after ciprofloxacin.
Correct Answer: A
Rationale: A: Ciprofloxacin (Cipro) is a fluoroquinolone antibiotic. Milk or yogurt decreases its absorption and should be avoided. B: Bismuth subsalicylate decreases the absorption of ciprofloxacin and should be avoided. C: Fennel will decrease, not increase, the absorption of the ciprofloxacin. D: Dietary calcium can be taken at any time; it is unaffected by ciprofloxacin.
For a client with suspected appendicitis, the nurse should expect to find abdominal tenderness in which quadrant?
- A. upper right
- B. upper left
- C. lower right
- D. lower left
Correct Answer: C
Rationale: The nurse should expect to find abdominal tenderness in the lower-right quadrant in a client with appendicitis.
The HCP prescribes a second antihypertensive medication for the client who has poorly controlled BP on one medication. If prescribed, which medication combination should the nurse question?
- A. Atenolol and metoprolol
- B. Metolazone and valsartan
- C. Captopril and furosemide
- D. Bumetanide and diltiazem
Correct Answer: A
Rationale: A: The nurse should question this medication combination. When two medications are used to treat hypertension, each should be from different drug classifications. Atenolol (Tenormin) and metoprolol (Lopressor) are both beta-adrenergic blockers and have the same general mechanism of action. B: Metolazone (Zaroxolyn) is a thiazide-like diuretic, and valsartan (Diovan) is an ARB. C: Captopril (Capoten) is an ACE inhibitor, and furosemide (Lasix) is a loop diuretic. D: Bumetanide (Bumex) is a loop diuretic, and diltiazem (Cardizem) is a calcium channel blocker.
The parent of the child brought to the ED states to the nurse, “My child is sweaty and shaky; I think some of my medication is gone.†The parent hands the nurse the medication bottle illustrated. Which action should the nurse take first?
- A. Start an infusion of D5W at 40 mL/hr.
- B. Give glucagon 1 mg subcutaneously.
- C. Check the child's blood glucose level.
- D. Determine how many tablets were taken.
Correct Answer: C
Rationale: A: Initiating an IV access for glucose administration is more time-consuming than giving glucose by the oral route or glucagon (GlucaGen) subcutaneously to a child who is still responsive. B: An oral form of glucose should be administered if the child is responsive and glucagon given only if the child is unresponsive or too uncooperative or upset to take oral glucose. Glucagon stimulates the release of liver glycogen and releases glucose into the circulation. C: The child may have ingested the glipizide (Glucotrol XL), a sustained-released hypoglycemic agent. The child's blood glucose level should be checked first to determine the appropriate treatment. D: Determining the number of tablets taken may delay the child's treatment.
The nurse is caring for an elderly client and providing education. Which of the following would be least appropriate?
- A. The nurse speaks in a loud voice.
- B. The nurse allows additional time after each instruction to allow the client to process.
- C. The nurse provides supplemental written resources.
- D. The nurse breaks up the education into multiple shorter sessions.
Correct Answer: A
Rationale: The nurse should not speak in a loud voice just because the client is elderly. The nurse should assess the client for a hearing impairment to see if additional assistance is required. However, elderly clients tend to require more time to process information, since their reaction time is slower, and they may benefit from more frequent, shorter sessions as they fatigue easily. Elderly clients are usually capable of absorbing supplemental written resources.