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The nurse is caring for a client who is very demanding. She frequently rings the bell and asks to have her pillow fluffed or the water glass filled. Which response by the nurse will likely be most effective?
- A. Answer the bell quickly each time she rings
- B. Say, 'I do not have time to be in your room constantly.'
- C. Say, 'Why are you so upset?'
- D. Say, 'You seem concerned about something.'
Correct Answer: D
Rationale: Acknowledging potential underlying concerns invites the client to express needs, reducing demands. Constant responses reinforce behavior, and dismissive or confrontational responses escalate tension.
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The nurse is reviewing the plan of care for multiple clients receiving opioids for pain management. Which client has the greatest risk for respiratory depression?
- A. 20-year-old client with chronic bronchitis who is receiving inhaled albuterol therapy every 4 hours
- B. 30-year-old client with opioid use disorder who had rotator cuff repair surgery this morning
- C. 50-year-old client with sleep apnea and left foot cellulitis who is scheduled for a bone scan later today
- D. 70-year-old client with chronic obstructive pulmonary disease who had knee replacement this morning
Correct Answer: D
Rationale: The 70-year-old with COPD is at highest risk for opioid-induced respiratory depression due to age-related reduced lung capacity and COPD-related impaired gas exchange. Chronic bronchitis and opioid use disorder increase risk but are less severe in this context.
A laboring woman has been pushing for one hour and is not making progress. The nurse knows that which of the following could hinder the descent of the fetus in the second stage of labor?
- A. A full bladder
- B. Paracervical block given during the first stage of labor
- C. Mother placed in a side-lying position
- D. Fetus in LOA (left occiput anterior) position
Correct Answer: A
Rationale: A full bladder obstructs fetal descent by occupying pelvic space, hindering labor progress, unlike anesthesia, positioning, or optimal fetal position.
A transfusion is ordered for a hospitalized client. The charge nurse asks the LPN to start the transfusion. What should the LPN do?
- A. Start the transfusion as ordered
- B. Be sure that dextrose is hanging and then hang the blood
- C. Tell the RN that LPNs are not allowed to hang blood
- D. Hang the blood only if an IV line is already established
Correct Answer: C
Rationale: LPNs typically cannot initiate blood transfusions due to scope of practice limitations, as it requires specialized monitoring, so the LPN should inform the RN.
A client at 20 weeks gestation reports 'running to the bathroom all the time,' pain with urination, and foul-smelling urine. Which question is most important for the nurse to ask when assessing the client?
- A. Are you having any pain in your lower back or flank area?
- B. Do you wipe from front to back after urinating?
- C. Have you found that you urinate more frequently since becoming pregnant?
- D. Have you had a urinary tract infection in the past?
Correct Answer: A
Rationale: Back or flank pain suggests pyelonephritis, a serious complication of UTI in pregnancy, requiring urgent evaluation. Hygiene, frequency, and history are relevant but less critical than assessing for systemic infection.
The nurse is reinforcing instructions to a postpartum client about cord care for the newborn. Which client statement indicates a need for further teaching?
- A. I can expect the cord to turn black in a few days
- B. I should let the cord fall off by itself
- C. I’ll give my newborn sponge baths until the cord falls off
- D. I’ll secure the diaper over the cord to protect it
Correct Answer: D
Rationale: Securing the diaper over the cord traps moisture, increasing infection risk. The cord turning black, falling off naturally, and sponge baths are correct cord care practices.