Nokea
The nurse is caring for a patient who is hard-of-hearing. Which of the following steps may be appropriate when communicating with the patient?
- A. Divide the verbal communication into smaller sections and address one at a time.
- B. Communicate only with written information.
- C. Ask multiple questions in a row quickly to make sure the client is remaining engaged.
- D. Frequently communicate without assistive devices to help the client improve their hearing.
Correct Answer: A
Rationale: For a client who is hard-of-hearing, verbal communication should be kept concise. If assistive devices are available, they should be used.
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To remove hard contact lenses from an unresponsive client, the nurse should:
- A. gently irrigate the eye with an irrigating solution from the inner canthus outward.
- B. grasp the lens with a gentle pinching motion.
- C. don sterile gloves before attempting the procedure.
- D. ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens.
Correct Answer: D
Rationale: To remove hard contact lenses, the upper and lower eyelids are gently maneuvered to help loosen the lens and slide it out of the eye. The lens must be situated on the cornea, not the sclera, before removal. An attempt to grasp a hard lens might result in a scratch on the cornea. Clean gloves are an option if drainage is present.
The LPN is preparing to clean a client's PEG tube. Which of the following tasks should the nurse perform? A. Gently remove crusty drainage from the site. B. Pull the tube in multiple directions to ensure it is secure. C. Thoroughly dry the skin around the tube site with a clean towel. D. Use mild soap to clean around the tube site. E. Apply talcum powder to the tube site.
- A. B, D, E
- B. A, B, C
- C. A, C, D
- D. C, D, E
Correct Answer: C
Rationale: LPNs caring for the PEG tube should be careful to not disrupt the tube, pull on the tube, or apply any ointment or powder near or on the tube. Talcum powder may irritate the stoma.
A 15 year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?
- A. Lab values of Potassium and Sodium
- B. Lab values of glucose and hemoglobin
- C. ECG
- D. CT scan
Correct Answer: A
Rationale: Diuretics can disturb the sodium and potassium balance, resulting in cardiac complications. Monitoring electrolyte levels is critical.
The LPN is observing a client using crutches for a leg injury. Which of these would indicate a need for more education?
- A. The client places the top padding 1-2 inches below the axilla with a firm grip on the handles.
- B. The client rests the axilla on the top padding and loosely grips the handles with hands.
- C. The client has a slight bend in the elbow when using the handles.
- D. When going down the stairs, the client leads with the injured leg.
Correct Answer: B
Rationale: Resting the axilla on the top of the crutch can cause nerve damage and the client should have a firm grip on the handles.
Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?
- A. The client verbalizes knowledge of a maintenance diet.
- B. The client demonstrates assertiveness with family.
- C. The client verbalizes her body size accurately.
- D. The client demonstrates control of obsessive behaviors.
Correct Answer: C
Rationale: Part of the problem for anorexic clients is an altered view of their body appearance (visualizing themselves as fat even when they are emaciated). Knowledge of a maintenance diet involves a knowledge deficit. Assertiveness with family involves possible resolution of family-dynamic issues. Control of obsessive behaviors involves psychological adaptation.