The nurse and a licensed practical nurse are caring for clients in a rheumatologist's office. Which task can the nurse assign to the licensed practical nurse?
- A. Administer methotrexate, an antineoplastic medication, IV.
- B. Assess the lung sounds of a client with RA who is coughing.
- C. Demonstrate how to use clothing equipped with Velcro fasteners.
- D. Discuss methods of birth control compatible with treatment medications.
Correct Answer: C
Rationale: Demonstrating Velcro clothing is within LPN scope. Methotrexate administration, lung assessment, and birth control discussion require RN judgment.
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The client recently diagnosed with SLE asks the nurse, 'What is SLE and how did I get it?' Which statement best explains the scientific rationale for the nurse's response?
- A. SLE occurs because the kidneys do not filter antibodies from the blood.
- B. SLE occurs after a viral illness as a result of damage to the endocrine system.
- C. There is no known identifiable reason for a client to develop SLE.
- D. This is an autoimmune disease that may have a genetic or hormonal component.
Correct Answer: D
Rationale: SLE is an autoimmune disease with genetic and hormonal influences. Kidney issues are a complication, viral triggers are secondary, and the cause is partially understood.
Which assessment data should make the nurse suspect the client has chronic allergies?
- A. Jaundiced sclera and jaundiced palms of hands.
- B. Pale, boggy, edematous nasal mucosa.
- C. Lacy white plaques on the oral mucosa.
- D. Purple or blue patches on the face.
Correct Answer: B
Rationale: Pale, boggy, edematous nasal mucosa indicates chronic allergic rhinitis. Jaundice, oral plaques, and facial patches suggest other conditions.
The nurse is admitting a client diagnosed with protein-calorie malnutrition secondary to AIDS. Which intervention should be the nurse's first intervention?
- A. Assess the client's body weight and ask what the client has been able to eat.
- B. Place in contact isolation and don a mask and gown before entering the room.
- C. Check the HCP's orders and determine what laboratory tests will be done.
- D. Teach the client about total parenteral nutrition and monitor the subclavian IV site.
Correct Answer: A
Rationale: Assessing weight and dietary intake provides baseline data for malnutrition management. Isolation is unnecessary, lab orders are secondary, and TPN teaching is premature.
Which signs/symptoms make the nurse suspect the most common opportunistic infection in the female client diagnosed with acquired immunodeficiency syndrome (AIDS)?
- A. Fever, cough, and shortness of breath.
- B. Oral thrush, esophagitis, and vaginal candidiasis.
- C. Abdominal pain, diarrhea, and weight loss.
- D. Painless violet lesions on the face and tip of nose.
Correct Answer: A
Rationale: Fever, cough, and shortness of breath indicate Pneumocystis pneumonia, the most common AIDS opportunistic infection. Candidiasis, GI symptoms, and Kaposi’s sarcoma are less frequent.
The 45-year-old client is diagnosed with primary progressive multiple sclerosis and the nurse writes the nursing diagnosis 'anticipatory grieving related to progressive loss.' Which intervention should be implemented first?
- A. Consult the physical therapist for assistive devices for mobility.
- B. Determine if the client has a legal power of attorney.
- C. Ask if the client would like to talk to the hospital chaplain.
- D. Discuss the client's wishes regarding end-of-life care.
Correct Answer: C
Rationale: Addressing anticipatory grieving involves exploring spiritual or emotional support, like a chaplain visit. Mobility devices, legal documents, and end-of-life discussions are secondary.
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