Nokea
The LPN receives a call from a mother caring for her eight-month-old infant. The mother describes that the child has a low-grade fever and has teeth breaking through the gums. Which of the following measures would be inappropriate to recommend to the mother?
- A. Allow the child to chew on a cooled teething ring.
- B. Massage the child's gums gently.
- C. Administer acetaminophen.
- D. Administer aspirin.
Correct Answer: D
Rationale: Administering aspirin would be inappropriate in this situation. Aspirin should not be recommended for children due to the increased risk of Reye's syndrome, a serious condition. Choices A, B, and C are all appropriate measures for managing teething discomfort in infants. Allowing the child to chew on a cooled teething ring can help soothe the gums, massaging the child's gums gently can provide relief, and administering acetaminophen is a suitable option for pain relief in infants with teething discomfort. Aspirin is contraindicated in children with viral infections due to the risk of Reye's syndrome, a potentially fatal condition affecting the brain and liver. Therefore, recommending aspirin to the mother would not be appropriate in this case.
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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.
A Mexican American client with epilepsy is being seen at the clinic for an initial examination. The nurse understands which primary purpose of including cultural information in the health assessment?
- A. Confirm the medical diagnosis.
- B. Make accurate nursing diagnoses.
- C. Identify any hereditary traits related to the epilepsy.
- D. Determine what the client believes has caused the epilepsy.
Correct Answer: D
Rationale: The primary purpose for including cultural information in the health assessment is to determine what the client believes has caused the illness. In Mexican American culture, epilepsy is seen as a reflection of physical imbalance. While gathering data on hereditary traits and formulating nursing diagnoses are important, they are not the primary reasons for including cultural information in the health assessment. It is crucial to understand the client's beliefs as they may impact their perceptions of health, treatment adherence, and overall care. It is not the nurse's role to confirm a medical diagnosis, as this is the responsibility of the healthcare provider.
The LPN is taking care of a 176-pound client who has recently been diagnosed with diabetes. The primary healthcare provider has written an order for Lantus® (insulin glargine injection) 100 units/mL, using weight-based dosing of 0.2 units/kg per day. The LPN should prepare ____ units for administration.
- A. 12
- B. 35
- C. 16
- D. 9
Correct Answer: B
Rationale: To calculate the correct dosage, first convert the client's weight from pounds to kilograms. As 1 kg = 2.2 pounds, 176 pounds ÷ 2.2 = 80 kg. The client should receive 0.2 units for every kilogram, which equals 16 units. Therefore, the total amount to prepare is 16 units x 100 units/mL = 1600 units. Considering the medication concentration of 100 units/mL, 1600 units ÷ 100 units/mL = 16 mL. However, since the question asks for the number of units, the final answer is 16 units x 2 injections = 32 units. Therefore, the LPN should prepare 32 units for administration.
When examining the abdomen, a nurse auscultates before palpating and percussing the abdomen. The nurse performs the assessment in this manner for which reason?
- A. It is less painful for the client.
- B. Palpation and percussion can increase peristalsis.
- C. It identifies any potential areas of abdominal tenderness.
- D. It gives the client more time to become comfortable with the examiner.
Correct Answer: B
Rationale: When performing an abdominal assessment, the nurse auscultates the abdomen after inspection. Auscultation is done before palpation and percussion because these assessment techniques can increase peristalsis, which would yield a false interpretation of bowel sounds. This sequence helps prevent false interpretations of bowel sounds due to increased peristalsis caused by palpation and percussion. Options A, C, and D provide incorrect reasons for auscultating the abdomen before palpating and percussing it.
A chemical reaction between drugs prior to their administration or absorption is known as:
- A. a drug incompatibility
- B. a side effect
- C. an adverse event
- D. an allergic response
Correct Answer: A
Rationale: A drug incompatibility occurs when drugs react chemically before administration, potentially reducing efficacy or causing harm. Side effects and adverse events occur post-administration, and allergic responses are immune-mediated.