Nokea
The LPN/LVN is to perform a sterile procedure. Which action will maintain a sterile field?
- A. Keeping the sterile field within the line of vision
- B. Opening sterile packages with sterile gloves
- C. Talking to others over the sterile field
- D. Handing the physician medicine over the sterile field
Correct Answer: A
Rationale: Keeping the sterile field in view ensures no contamination occurs, maintaining sterility during the procedure.
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An African-American client is admitted with full thickness burns over 40% of his body. In addition to the CBC and complete metabolic panel, the physician is likely to request which additional lab work?
- A. Erythrocyte sedimentation rate
- B. Indirect Coombs
- C. C reactive protein
- D. Sickledex
Correct Answer: D
Rationale: Sickle cell anemia and sickle cell trait are more prevalent in African American clients. The Sickledex test detects the presence of sickle cell anemia and sickle cell trait. Trauma can trigger a sickle cell crisis, which would complicate the treatment of the client. Answers A and C indicate inflammation, so they are incorrect. Answer B is incorrect because it detects circulating antibodies against RBCs.
One hour after receiving 7 U of regular insulin, the client presents with diaphoresis, pallor, and tachycardia. The priority nursing action would be to
- A. notify the physician.
- B. call the lab for a blood glucose level.
- C. offer the client milk and crackers.
- D. administer glucagon.
Correct Answer: C
Rationale: Diaphoresis, pallor, and tachycardia indicate hypoglycemia, a medical emergency. Milk and crackers provide fast-acting carbohydrates. Options A, B, and D delay treatment or are reserved for severe cases.
In providing care to a 14 year-old adolescent with scoliosis, which of the following will be most difficult for this client?
- A. Compliance with treatment regimens
- B. Looking different from their peers
- C. Lacking independence in activities
- D. Reliance on family for their social support
Correct Answer: B
Rationale: Looking different from their peers. Conformity is critical at age 14, and visible differences due to scoliosis treatment can be challenging.
An infant is admitted for vomiting and diarrhea. The infant's anterior fontanelle is depressed, and he has a fever of 103.2°F (39.5°C).
Which of the following nursing actions would be MOST appropriate?
- A. Determine daily weights and evaluate weight loss.
- B. Evaluate infant's ability to take in fluids.
- C. Place a full bottle of Pedi-Lyte at the bedside.
- D. Start an intravenous infusion.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. Is there an appropriate assessment? Yes. (1) assessment, correct information, but is not what the question asks for (2) correct-assessment, will assist in determining if hydration can be done through oral fluids alone (3) implementation, does not do anything to improve the situation; placing a full bottle at the bedside doesn't guarantee that the infant is taking fluids (4) implementation, would be implemented later
The nurse is caring for an adult who has kidney stones. Which action is essential for the nurse to take?
- A. Take blood pressure frequently
- B. Keep the client on bed rest
- C. Position the client supine
- D. Strain all urine
Correct Answer: D
Rationale: Straining urine captures kidney stones for analysis, guiding treatment. Blood pressure, bed rest, or positioning are not primary.