Nokea
The nurse is caring for a client on the oncology unit. Which nursing activity is appropriate to delegate to the unit LPN?
- A. obtaining vital signs
- B. administering blood
- C. administering IV pain medication
- D. administering chemotherapy if the nurse is busy with another client
Correct Answer: A
Rationale: Obtaining vital signs is within the LPN’s scope. Administering blood, IV pain medication, or chemotherapy typically requires RN expertise.
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After the physician performs an amniotomy, the nurse's first action should be to assess the:
- A. Degree of cervical dilation
- B. Fetal heart tones
- C. Client's vital signs
- D. Client's level of discomfort
Correct Answer: B
Rationale: Post-amniotomy, assessing fetal heart tones is critical to detect potential cord prolapse or distress.
The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
- A. Intravenous access supplies
- B. Emergency intubation equipment
- C. Intravenous fluid-administration pump
- D. Supplemental oxygen
Correct Answer: B
Rationale: Emergency intubation equipment is essential for LTB due to the risk of airway obstruction requiring immediate intervention.
A client is confused after receiving morphine for analgesia and repeatedly tries to pull out the intravenous (IV) line in her left arm. Which of the following actions is the best initial solution?
- A. Attempt to camouflage the IV and tie a piece of tubing to the bedrail so the client can pull on that safely.
- B. Apply wrist restraints.
- C. Apply wrist and vest restraints.
- D. Discontinue the IV line and reinsert at a more distant site.
Correct Answer: A
Rationale: Camouflaging the IV and providing a safe alternative (A) is a least-restrictive, non-invasive initial approach to prevent the client from pulling out the IV. Restraints (B, C) should be a last resort, and discontinuing the IV (D) is unnecessary.
When examining an 80-year-old client with chronic COPD receiving home health care, the nurse notes that over the previous 48 hours the client has developed scattered painful pustular lesions on the right arm near the elbow (see photo), on the back of the neck, the face, and on both legs. Which of the following does the nurse suspect is the most likely cause of the lesions?
- A. Psoriasis
- B. Herpes zoster
- C. MRSA
- D. Contact dermatitis
Correct Answer: C
Rationale: Painful pustular lesions in a client with chronic illness suggest MRSA (C), a common healthcare-associated infection. Psoriasis (A) presents with scaly plaques, herpes zoster (B) follows a dermatomal pattern, and contact dermatitis (D) is typically itchy, not pustular.
A client with increased intracranial pressure is placed on mechanical ventilation with hyperventilation. The nurse knows that the purpose of the hyperventilation is to:
- A. Prevent the development of acute respiratory failure
- B. Decrease cerebral blood flow
- C. Increase systemic tissue perfusion
- D. Prevent cerebral anoxia
Correct Answer: B
Rationale: Hyperventilation reduces PaCO2, causing vasoconstriction and decreasing cerebral blood flow to reduce intracranial pressure.