Nokea
The nurse is caring for a client who is experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? Select all that apply.
- A. Prepare to suction the client.
- B. Turn the client to a side-lying position.
- C. Restrain the client's upper extremities.
- D. Request assistance from other staff members.
- E. Use a tongue blade to depress the client's tongue.
Correct Answer: A,B,D
Rationale: Suctioning, side-lying position, and assistance protect the client. Restraining or using a tongue blade can cause injury.
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A 1-year-old child who goes to day care is recovering from an episode of otitis media. Which intervention is most important for the nurse to reinforce to the parents in order to prevent recurrence?
- A. Exclusive breastfeeding
- B. Not sending the child to day care
- C. Preventing water from entering the ear
- D. Smoking cessation by the parents
Correct Answer: D
Rationale: Parental smoking increases the risk of recurrent otitis media due to secondhand smoke exposure.
The registered nurse delegates actions related to the care of colostomies to the practical nurse. Which actions should the practical nurse question as being outside the licensed practical nurse's scope of practice? Select all that apply.
- A. Assessment of the postoperative stoma
- B. Client assistance with application of the pouch
- C. Documentation of emptied output
- D. Initial client education relating to ostomy care
- E. Initial irrigation of postoperative descending colostomy
Correct Answer: A,D
Rationale: Assessment and initial education require nursing judgment, which is outside the LPN's scope. Other tasks are within their scope.
The practical nurse is caring for a 48-year-old executive on the cardiac unit who has just been diagnosed with primary hypertension. Which teaching strategy would be most effective to reinforce prior teaching from the registered nurse?
- A. Leave diet pamphlets for the client to review at a later time
- B. Refer the client to the nurse case manager to follow up with diet instructions
- C. Sit with the client during meal selections and assist with identification of low sodium options
- D. Turn the television on in the client's room to the patient education channel to watch
Correct Answer: C
Rationale: Active participation in meal selection reinforces learning and promotes adherence to a low-sodium diet.
The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial post-procedure monitoring plan should include what? Select all that apply.
- A. Level of alertness
- B. Lung sounds
- C. Oxygen saturation
- D. Respiratory pattern
- E. Temperature
- F. Urine output
Correct Answer: A,B,C,D
Rationale: Monitoring alertness, lung sounds, oxygen saturation, and respiratory pattern detects complications like pneumothorax or respiratory distress.
A client with a fracture of the radius had a plaster cast applied 2 days ago. The client complains of constant pain and swelling of the fingers. The first action of the nurse should be
- A. elevate the arm no higher than heart level
- B. remove the cast
- C. assess capillary refill of the exposed hand and fingers
- D. apply a warm soak to the hand
Correct Answer: C
Rationale: A deterioration in neurovascular status indicates the development of compartment syndrome (elevated tissue pressure within a confined area) which requires immediate pressure-reducing interventions.