Nokea
The NA tells the nurse that the unit's small-adult BP cuff cannot be found and that the client's arm is too small to use a regular adult-sized cuff. Which direction should the nurse give to the NA?
- A. Document the other vital signs and note that the proper-fitting BP cuff is not available.
- B. Go to another nursing unit to obtain their small-adult BP cuff, and take the client's BP.
- C. Use the regular-sized BP cuff and add 10 to the diastolic and systolic BP readings.
- D. If the cuff closes around the arm, take the client's BP using the regular adult cuff.
Correct Answer: B
Rationale: B: A correct-sized cuff ensures accurate BP readings. A: Omitting BP is inappropriate. C: Adjusting readings is inaccurate. D: A too-large cuff gives falsely low readings.
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The focus of a nurse case manager is:
- A. nursing care needs at discharge.
- B. the comprehensive care needs of the client for continuity of care.
- C. client education needs upon discharge.
- D. financial resources for needed care.
Correct Answer: B
Rationale: By definition, case management is a process of providing for the comprehensive care needs of a client for continuity of care throughout the health care experience.
A client with dysphagia is ready to eat lunch. Which of these foods on the tray would be best to start with when assisting the client?
- A. diced fruit
- B. apple juice with a liquid thickener
- C. Jell-O™
- D. toast
Correct Answer: B
Rationale: A client with dysphagia is at risk for aspiration. A liquid thickener will allow the LPN to assess the client's ability to swallow prior to introducing pureed or solid foods. Since Jell-O™ melts into a clear liquid, it should not be used when assessing swallowing ability.
Which type of diet should the nurse provide to help a client who has major burns maintain a positive nitrogen balance?
- A. high protein
- B. high carbohydrate
- C. low carbohydrate
- D. low protein
Correct Answer: A
Rationale: Clients with burns are hypermetabolic and require increased protein levels to maintain a positive nitrogen balance. Choices 2 and 3 are incorrect; carbohydrate levels do not help clients to meet this goal. Choice 4 is incorrect; a client with major burns requires a high-protein diet.
The nurse is using Cognitive-Behavioral methods of pain control and knows that these methods can be expected to do all the following except:
- A. completely relieve all pain.
- B. provide benefit by restoring the client's sense of self-control.
- C. help the client to control symptoms.
- D. help the client actively participate in his or her own care.
Correct Answer: A
Rationale: These interventions (strategies) help the client in all areas of client well-being. Focusing on perception and thought, cognitive techniques are designed to influence how one interprets events and bodily sensations.
The nurse applies a warm, moist compress to the site where an IV solution has infiltrated. Which response is correct when the client asks the purpose of the compress?
- A. The application of moist heat will alter tissue sensitivity by producing numbness.
- B. The application of moist heat will decrease the metabolic needs of the involved tissues.
- C. The application of moist heat will stop the local release of histamine in the tissues.
- D. The application of moist heat will increase blood flow and accelerate tissue healing.
Correct Answer: D
Rationale: D: Warm compresses increase blood flow, promoting healing. A: Cold causes numbness. B: Heat increases metabolic needs. C: Cold reduces histamine release.