Nokea
The nurse is caring for assigned clients. The nurse should first check the client with
- A. sickle cell disease who has new onset pain rated as 9 on a scale of 0-10
- B. pneumonia who has a temperature of 100.6°F (38.1°C) and is receiving IV antibiotics
- C. Graves’ disease who has a heart rate of 110/min and a blood pressure of 122/85 mm Hg
- D. diabetes mellitus who has an elevated serum glucose level and is requesting insulin lispro prior to a meal
Correct Answer: A
Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.
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The nurse is teaching a client about newly prescribed amlodipine. Which adverse effect would be most important for the nurse to include?
- A. Depression
- B. Dizziness
- C. Dry cough
- D. Erectile dysfunction
Correct Answer: B
Rationale: Dizziness, due to amlodipine’s vasodilatory effect, is a common and critical side effect, risking falls, especially in the elderly. Depression, cough, and erectile dysfunction are less common or associated with other drugs.
The nurse is talking with a client with obsessive-compulsive personality disorder who is scheduled for a colonoscopy. Due to a computer malfunction, the procedure is being postponed by 2 hours. Which of the following responses by the client would be consistent with obsessive-compulsive personality disorder?
- A. How dare they change my appointment time. I insist that the procedure be done at the scheduled time
- B. I do not understand why they would do this. It seems like they just want to make things difficult for me
- C. That is not a problem. I can come in whenever it is convenient for everyone
- D. This is unacceptable. I had my whole day planned out and I cannot change my plan
Correct Answer: D
Rationale: Obsessive-compulsive personality disorder involves rigidity and need for control, so resistance to schedule changes is typical. The other responses reflect anger, paranoia, or flexibility, less characteristic of the disorder.
All of the following tasks need to be done. Which one can the LPN/LVN safely delegate to the certified nursing assistant (CNA)?
- A. Tube feeding for a client with a nasogastric tube
- B. Routine vital signs for a group of clients
- C. Blood pressure monitoring for a client who is in congestive heart failure
- D. Wound care for a client with a stage III decubitus ulcer
Correct Answer: B
Rationale: Routine vital signs are within a CNA's scope of practice. Tube feeding, specialized blood pressure monitoring, and wound care require nursing judgment and skills.
A client with advanced Alzheimer’s dementia is admitted to a skilled nursing facility for delirium. The health care provider prescribes ambulation with partial weight bearing. Which would be the most appropriate method for the nurse to use to transfer this client safely?
- A. 1-person stand and pivot with a gait belt and walker
- B. 2-person full-body sling lift
- C. 2-person motorized standing-assist lift
- D. 2-person stand and pivot with a gait belt and walker
Correct Answer: D
Rationale: A 2-person stand and pivot with a gait belt and walker ensures safety for a client with dementia and partial weight bearing, accounting for confusion and weakness. One-person transfer risks falls, and lifts are excessive for ambulation.
The nurse is reinforcing teaching with a client in the postpartum period who is breastfeeding and has breast engorgement. Which of the following information should the nurse include?
- A. Apply ice packs to your breasts for 15 to 20 minutes before breastfeeding
- B. Allow your baby to nurse for at least 10 to 15 minutes on each breast
- C. Temporarily decrease the frequency of your breastfeeding
- D. Avoid taking NSAIDs for discomfort while breastfeeding
Correct Answer: B
Rationale: Nursing for 10-15 minutes per breast relieves engorgement by emptying milk ducts. Ice packs are used after, not before, feeding; decreasing frequency worsens engorgement; and NSAIDs are safe for breastfeeding.