Nokea
The nurse and a licensed practical nurse (LPN) are caring for a group of clients. Which nursing task should not be assigned to the LPN?
- A. Administer a skeletal muscle relaxant to a client diagnosed with low back pain.
- B. Discuss bowel regimen medications with the HCP for the client on strict bedrest.
- C. Draw morning blood work on the client diagnosed with bacterial meningitis.
- D. Teach self-catheterization to the client diagnosed with multiple sclerosis.
Correct Answer: D
Rationale: Teaching self-catheterization requires nursing judgment and patient education, outside LPN scope. Administering medications, discussing with HCP, and drawing blood are within LPN scope.
You may also like to solve these questions
The client is diagnosed with myasthenia gravis. Which intervention should the nurse implement when administering the anticholinesterase pyridostigmine (Mestinon)?
- A. Administer the medication 30 minutes prior to meals.
- B. Instruct the client to take with eight (8) ounces of water.
- C. Explain the importance of sitting up for one (1) hour after taking medication.
- D. Assess the client's blood pressure prior to administering medication.
Correct Answer: A
Rationale: Administering pyridostigmine 30 minutes before meals maximizes muscle strength for swallowing. Water volume, sitting up, and BP checks are not specific requirements.
The client diagnosed with myasthenia gravis is being discharged home. Which intervention has priority when teaching the client's significant others?
- A. Discuss ways to help prevent choking episodes.
- B. Explain how to care for a client on a ventilator.
- C. Teach how to perform passive range-of-motion exercises.
- D. Demonstrate how to care for the client's feeding tube.
Correct Answer: A
Rationale: Preventing choking is critical due to dysphagia in myasthenia gravis. Ventilator care, ROM, and feeding tubes are less common or secondary.
The nurse is explaining Systemic Inflammatory Response Syndrome (SIRS) to the client's significant other. Which statement best describes SIRS?
- A. SIRS is a response of the body when it has sustained a major burn or crushing injury in a motor-vehicle accident.
- B. SIRS is a response by the body to some type of injury or insult; the insult can be infectious or noninfectious in nature.
- C. SIRS only occurs when the body is overwhelmed with an infectious organism such as streptococcus bacteria.
- D. SIRS occurs when the body is allergic to the prescribed antibiotic and the body tries to recover from the allergic response.
Correct Answer: B
Rationale: SIRS is a systemic response to various insults (e.g., infection, trauma, surgery), not limited to specific causes. Burns, infections, and allergies are subsets.
The client diagnosed with AIDS is angry and yells at everyone entering the room, and none of the staff members wants to care for the client. Which intervention is most appropriate for the nurse manager to use in resolving this situation?
- A. Assign a different nurse every shift to the client.
- B. Ask the HCP to tell the client not to yell at the staff.
- C. Call a team meeting and discuss options with the staff.
- D. Tell one (1) staff member to care for the client a week at a time.
Correct Answer: C
Rationale: A team meeting fosters collaboration to address the client’s behavior and staff concerns. Rotating nurses, HCP intervention, or single-nurse assignment are less effective.
The client in the emergency department begins to experience a severe anaphylactic reaction after an initial dose of IV penicillin, an antibiotic. Which interventions should the nurse implement? Select all that apply.
- A. Prepare to administer Solu-Medrol, a glucocorticoid, IV.
- B. Request and obtain a STAT chest x-ray.
- C. Initiate the rapid response team.
- D. Administer epinephrine, an adrenergic blocker, SQ then IV continuous.
- E. Assess the client's pulse and respirations.
Correct Answer: A,C,E
Rationale: Solu-Medrol, rapid response team, and vital sign assessment address anaphylaxis. Chest x-ray is unnecessary, and epinephrine is an agonist, not a blocker.