Nokea
The nurse in the outpatient clinic is speaking with a client diagnosed with cerebral arteriovenous malformation. Which statement would be a priority for the nurse to report to the health care provider?
- A. I got short of breath this morning when I worked out
- B. I have cut down on smoking to ½ pack per day
- C. I haven't been feeling well, so I have been sleeping a lot.
- D. I took an acetaminophen in the waiting room for this bad headache.
Correct Answer: D
Rationale: A bad headache in a client with cerebral arteriovenous malformation may indicate increased intracranial pressure or bleeding, requiring urgent reporting. Other symptoms are less specific and less immediately critical.
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The nurse caring for multiple clients on a medical-surgical unit should delegate which action to the nursing assistant?
- A. Assist client, post hip fracture repair, to the bathroom
- B. Check the appearance of client's wound
- C. Discontinue nasogastric tube if client tolerates oral liquids
- D. Offer orange juice to client if bedside glucose reading is <70 mg/dL (3.9 mmol/L)
Correct Answer: A
Rationale: Assisting with mobility, such as to the bathroom, is within the nursing assistant's scope. Wound assessment, tube discontinuation, and treating hypoglycemia require nursing judgment and are outside their scope.
The licensed practical nurse is working with a registered nurse to care for a client who has just returned to the cardiac unit after having a percutaneous coronary intervention. Which actions assigned by the registered nurse should the practical nurse question as outside of the practical nurse's scope of practice? Select all that apply.
- A. Administering oral pain medication if client reports low back pain
- B. Checking for bleeding at the catheter insertion site every 15 minutes
- C. Performing post-procedure vital sign measurements
- D. Reinforcing instructions to keep the involved extremity straight
- E. Reviewing ECG for dysrhythmias
Correct Answer: E
Rationale: Reviewing ECGs for dysrhythmias requires advanced assessment skills beyond LPN scope. Administering medication, checking for bleeding, taking vital signs, and reinforcing instructions are within LPN scope if trained.
A client is being admitted with a diagnosis of active shingles with a disseminated rash. Which room assignment is most appropriate for this client?
- A. A private room with contact and droplet precautions
- B. A private room with negative airflow and contact and airborne precautions
- C. A private room with positive airflow and airborne precautions
- D. A semi-private 2-bed room with standard precautions
Correct Answer: B
Rationale: Disseminated shingles in immunocompromised clients requires contact and airborne precautions due to varicella-zoster virus transmission risk. A private room with negative airflow prevents spread. Droplet or standard precautions are insufficient, and positive airflow is inappropriate.
Which finding is commonly noted in the client with bladder cancer?
- A. Painless hematuria.
- B. Bladder spasms.
- C. Lower back pain.
- D. Urinary frequency.
Correct Answer: A
Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often the earliest sign. Other symptoms may occur but are less specific.
During an assessment of a client with cardiomyopathy, the nurse finds that the systolic blood pressure has decreased from 145 to 110 mm Hg and the heart rate has risen from 72 to 96 beats per minute and the client complains of periodic dizzy spells. The nurse instructs the client to
- A. increase fluids that are high in protein
- B. restrict fluids
- C. force fluids and reassess blood pressure
- D. limit fluids to non-caffeine beverages
Correct Answer: C
Rationale: Postural hypotension, a decrease in systolic blood pressure of more than 15 mm Hg and an increase in heart rate of more than 15 percent usually accompanied by dizziness indicates volume depletion, inadequate vasoconstrictor mechanisms, and autonomic insufficiency.