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The nurse is admitting a patient diagnosed with a stroke. The healthcare provider writes orders for 'ROM as needed.' What should the nurse do next?
- A. Restrict the patient's mobility as much as possible.
- B. Realize the patient is unable to move extremities.
- C. Move all the patient's extremities.
- D. Further assess the patient.
Correct Answer: D
Rationale: The correct answer is to further assess the patient. 'ROM as needed' stands for Range of Motion, indicating that the patient should have their limbs moved to maintain joint flexibility and muscle strength. Before initiating any movements, it is crucial to assess the patient's current condition to determine their abilities and limitations. Restricting mobility (choice A) is not appropriate as it contradicts the purpose of ROM exercises. Realizing the patient is unable to move extremities (choice B) assumes without assessment and can lead to inappropriate care. Moving all the patient's extremities (choice C) without assessing the patient first can be harmful, as it may cause pain or injury if done incorrectly. Therefore, further assessment is necessary to provide safe and effective care.
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A client with a history of hypertension is prescribed a beta-blocker. Which side effect should the LPN/LVN monitor for in this client?
- A. Increased appetite
- B. Dry mouth
- C. Bradycardia
- D. Insomnia
Correct Answer: C
Rationale: The correct side effect that the LPN/LVN should monitor for in a client prescribed a beta-blocker is bradycardia. Beta-blockers work by slowing down the heart rate, which can lead to bradycardia as a common side effect. Monitoring the client's heart rate is crucial, as bradycardia can be a serious condition. Choices A, B, and D are incorrect because increased appetite, dry mouth, and insomnia are not typically associated with beta-blockers. Increased appetite is more commonly linked to certain medications like corticosteroids, dry mouth can be a side effect of anticholinergic medications, and insomnia may be a side effect of stimulant medications.
The healthcare professional is assessing a client who is post-operative following abdominal surgery. Which assessment finding would require immediate intervention?
- A. Absent bowel sounds
- B. Pain level of 8/10
- C. Temperature of 100.4°F
- D. Saturated abdominal dressing
Correct Answer: D
Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention. This finding suggests a potential surgical site issue that needs urgent attention to prevent further complications. Absent bowel sounds, pain level, and a slightly elevated temperature are common post-operative findings that may not necessarily require immediate intervention compared to a saturated abdominal dressing. Absent bowel sounds can be common after surgery due to anesthesia but may resolve with time. Pain and slightly elevated temperature are expected post-operative findings that can be managed with appropriate pain relief and monitoring. However, a saturated abdominal dressing indicates a potential ongoing issue at the surgical site that needs prompt assessment and intervention to prevent complications.
A client has restraints on each extremity. Which of the following assessments should the nurse perform first?
- A. Peripheral pulses
- B. Comfort level
- C. Elimination needs
- D. Skin integrity
Correct Answer: A
Rationale: When a client is restrained, the nurse should prioritize assessing peripheral pulses first. This assessment is crucial to monitor circulation and ensure the restraints are not impeding blood flow. Comfort level, elimination needs, and skin integrity are also important assessments; however, assessing peripheral pulses takes precedence to prevent complications such as impaired circulation and tissue damage. By assessing peripheral pulses initially, the nurse can promptly identify and address any circulation issues, which are critical in preventing serious complications.
During an assessment, a nurse is evaluating the breath sounds of an adult client diagnosed with pneumonia. Which of the following actions should the nurse take?
- A. Follow a systematic pattern from side-to-side moving down the client's chest.
- B. Ask the client to breathe in deeply through their nose.
- C. Instruct the client to sit upright with their head slightly tilted backward.
- D. Place the diaphragm of the stethoscope on the client's chest.
Correct Answer: A
Rationale: When assessing breath sounds in a client with pneumonia, the nurse should follow a systematic pattern from side-to-side moving down the client's chest. This approach ensures a comprehensive evaluation of breath sounds across different lung fields. Asking the client to breathe in deeply through their nose (Choice B) is not necessary for assessing breath sounds. Instructing the client to sit upright with their head slightly tilted backward (Choice C) is not directly related to assessing breath sounds and may not be required. Placing the diaphragm of the stethoscope on the client's chest (Choice D) is not the correct technique for auscultating breath sounds, as the diaphragm should be used for this purpose.
What action should a healthcare professional planning to insert an IV for an older adult client take?
- A. Place the client's arm in a dependent position.
- B. Place the client's arm in a flexed position.
- C. Elevate the client's arm to the level of the heart.
- D. Use a tourniquet above the insertion site.
Correct Answer: A
Rationale: The correct action for a healthcare professional planning to insert an IV for an older adult client is to place the client's arm in a dependent position. This positioning helps with vein prominence and facilitates easier IV insertion by enhancing blood flow and distending the veins. Placing the arm in a flexed position or elevating it to the level of the heart can impede vein visualization and make insertion more challenging. Using a tourniquet above the insertion site is a step in the IV insertion process but is not the initial action to take when preparing for the procedure.