Nokea
The LPN/LVN is to assist the school nurse in scoliosis screening. What instructions should be given to the students?
- A. Wear a bathing suit under your clothes on the examination day.
- B. Bring a urine sample to school.
- C. Do not wash your hair the night before the exam.
- D. Wash your feet well the morning of the exam.
Correct Answer: A
Rationale: A bathing suit allows easy spinal visualization during scoliosis screening, ensuring modesty and efficiency.
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A client scheduled for a femoral popliteal bypass is to be assigned to a semi-private room. Which client would be the most suitable roommate for the client with a femoral popliteal bypass graft?
- A. A client with a pituitary tumor
- B. A client with respiratory sarcoidosis
- C. A client with a diabetic ulcer
- D. A client with a closed fracture of femur
Correct Answer: A
Rationale: The client with a pituitary tumor is the most suitable roommate as they are unlikely to have an infectious condition or mobility issues that could complicate recovery. Respiratory sarcoidosis may involve respiratory issues, increasing infection risk. A diabetic ulcer poses an infection risk due to potential open wounds. A closed femur fracture may involve similar mobility restrictions, complicating room logistics.
The nurse is giving unlicensed assistive personnel directions for bathing a client who has a surgical incision infected with methicillin-resistant Staphylococcus aureus. Which instructions would be most effective for reducing infection?
- A. Assist the client to the shower and provide directions to use antibacterial soap
- B. Delay the bath until the client has received antibiotic therapy for 24 hours
- C. Use a bath basin with warm water and a new washcloth for each body area
- D. Use packaged pre-moistened cloths containing chlorhexidine to bathe the client
Correct Answer: D
Rationale: Chlorhexidine cloths effectively reduce MRSA. Antibacterial soap is less specific, delaying the bath is unnecessary, and a bath basin risks contamination.
The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply.
- A. A visitor talking in the waiting room states that the client has alcoholism
- B. The licensed practical nurse (LPN) has the client's report sheet in a pocket when going home
- C. The nursing assistant tells a client that the hospital roommate went for a gallbladder test
- D. The registered nurse tells a visitor to wear a mask because the client is on isolation precautions
- E. Two LPNs are discussing a possible cure for AIDS on a crowded elevator
Correct Answer: A,B,C
Rationale: Visitor disclosure , taking reports home , and sharing roommate info violate confidentiality. Isolation precautions and general discussion do not.
The nurse is providing end-of-life care for a client. The client's spouse is crying and asks the nurse, 'Will you please stay with us?' Which of the following responses would be most appropriate for the nurse to make?
- A. I can come back at the end of my shift when I am able to stay longer.
- B. I will ask a friend or family member to stay with you if you would like.
- C. I can stay and sit with you for a short time if you would like.
- D. I will contact the chaplain to sit with you and your spouse
Correct Answer: C
Rationale: Offering to stay briefly provides immediate comfort while balancing duties. Delaying , delegating to others , or involving a chaplain may not address the spouse's immediate emotional needs.
A client is receiving Vincristine (Marqibo). The client should be taught that the medication can:
- A. Cause diarrhea
- B. Change the color of her urine
- C. Cause mental confusion
- D. Cause changes in taste
Correct Answer: C
Rationale: Vincristine can cause neurotoxicity, including mental confusion. Diarrhea, urine color changes, and taste alterations are less common.