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The nurse is assessing the client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding requires immediate intervention by the nurse?
- A. Nasogastric tube to low intermittent suction has small amounts of dark bloody returns.
- B. Oxygen saturation level is 92%, and oxygen by nasal cannula is set at 2 liters.
- C. The incisional dressing has a 25-cent-piece-sized shadow of new drainage.
- D. The Jackson-Pratt drain is round in shape with 30 mL serosanguineous drainage.
Correct Answer: D
Rationale: D: A round JP drain indicates lost suction, requiring immediate emptying and compression. A: Minor bloody NG returns are normal post-surgery. B: 92% saturation is adequate. C: Small drainage is monitorable.
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Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct Answer: B
Rationale: Compliance or performance at the minimally acceptable level is not considered quality care.
A nurse is assessing a patient's right lower extremity. The extremity is warm to touch, red and swollen. The patient is also running a low fever. Which of the following conditions would be the most likely cause of the patient's condition?
- A. Herpes
- B. Scleroderma
- C. Dermatitis
- D. Cellulitis
Correct Answer: D
Rationale: Inflammation of cellular tissue associated with a fever most likely indicates cellulitis.
The LPN is placing a Foley in a female client. Place the following steps in the appropriate order.A.Prepare the sterile field., B.Separate labia with non-dominant hand., C.Clean the urinary meatus using cleansing solutions and forceps. D. Inflate catheter balloon. E. Place the client in a supine position with flexed knees. F. Place lubricant on catheter. G. Place catheter in meatus with dominant (sterile) hand
- A. E, A, B, F, G, C, D
- B. A, E, B, F, G, D, C
- C. A, E, F, B, C, G, D
- D. E, A, F, B, C, G, D
Correct Answer: D
Rationale: The LPN should follow the correct order of catheter insertion to ensure the catheter is inserted safely. Any other variant of insertion may cause compromise of sterility and client harm.
In teaching clients with Buck's Traction, the major areas of importance should be:
- A. nutrition, ROM exercises.
- B. ROM exercises, transportation.
- C. nutrition, elimination, comfort, safety.
- D. elimination, safety, isotonic exercises.
Correct Answer: C
Rationale: Nutrition, elimination, comfort, and safety are the major areas of importance. The diet should be high in protein with adequate fluids.
A hospital discharge planning nurse is making arrangements for a client who has an epidural catheter for continuous infusion of opioids to be placed in a long-term care facility. The family prefers a facility in its neighborhood to facilitate visiting. The neighborhood facility has never cared for a client with this type of need. What is the most appropriate action by the discharge planning nurse?
- A. Arrange for immediate in-services for the long-term care facility staff on pain management using epidural catheters
- B. Explain the situation to the client and family and seek another long-term care facility for discharge from the hospital
- C. Encourage the family to hire private duty nurses skilled in epidural catheter pain management to allow the client to be transferred to the neighborhood facility
Correct Answer: B
Rationale: Transferring to a facility unprepared for epidural catheter management risks client safety. Finding a capable facility ensures continuity of care.