Nokea
The LPN/LVN is making assignments in a long-term care facility. Staff on duty include another LPN and a new certified nursing assistant. Which client can most safely be assigned to the nursing assistant?
- A. Ms. A., 92 years old, has dementia and advancing congestive heart failure (CHF).
- B. Ms. B., 83 years old, has Alzheimer's and Parkinson's and is ambulatory with assistance.
- C. Mr. C., 76 years old, has just been transferred from an acute care facility where he had a total hip replacement four days ago.
- D. Mr. D., 29 years old, had a closed head injury and is in a semi-vegetative state with a tracheostomy and a gastrostomy.
Correct Answer: B
Rationale: Ms. B's ambulatory status with assistance aligns with CNA tasks like hygiene and transfers, safest for a new CNA compared to complex needs.
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A client has severe second- and third-degree burns over 75% of his body.
The nurse would be MOST concerned if which of the following was observed?
- A. Epigastric pain.
- B. Restlessness.
- C. Tachypnea.
- D. Lethargy.
Correct Answer: C
Rationale: Strategy: Determine how each answer relates to burns. (1) insignificant for burn client (2) may be due to pain (3) correct-body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool clammy skin, tachycardia, tachypnea, and pale color (4) may be due to pain
A client with severe multiple trauma injuries from a motor vehicle accident.
After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST?
- A. Limit visiting hours to promote optimal rest.
- B. Arrange for clergy to visit with the client and family as requested.
- C. Arrange for a psychologist to visit with the family.
- D. Arrange for the family to meet with a social worker to discuss financial aid.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate (2) correct-would provide the appropriate spiritual support necessary during a crisis (3) inappropriate for the data given in the situation (4) inappropriate for the data given in the situation
The physician suggests play therapy for a 7-year-old girl who is having some difficulty adjusting to her parents' impending divorce. The nurse knows this type of therapy is useful because
- A. young children have difficulty verbalizing emotions.
- B. children hesitate to confide in anyone but their parents.
- C. play is an enjoyable form of therapy for children.
- D. play therapy is helpful in preventing regression.
Correct Answer: A
Rationale: children have difficulty putting feelings into words; play is how they express themselves
A client on suicide precautions is verbalizing other options besides suicide, appears to be responding to antidepressant medication, is sleeping and eating better, and has indicated a willingness to interact more with family members.
Based on this data, which of the following nursing actions is MOST appropriate?
- A. Recommend that the physician decrease the client's medication dosage.
- B. Recommend that the treatment team reevaluate the client's treatment plan.
- C. Give the client privileges to walk around the hospital by himself.
- D. Ask the family to begin planning for the client's discharge.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) may reverse the client's progress (2) correct-data suggests that client is beginning to benefit from treatment; entire treatment team should share data and make a decision about the suicide precautions so that restrictions are changed gradually based on a full-data picture (3) may be the team's decision, but not until a thorough review of the case is completed (4) premature
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Jugular vein distension.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Jugular vein distension suggests fluid overload, a serious complication of IV fluids, potentially leading to heart failure. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 80 bpm, and urine output 50 mL/hour indicate stability.