Nokea
The nurse is caring for several hospitalized children with the following diagnoses. Which disorder is likely to result in metabolic acidosis?
- A. Severe diarrhea for 24 hours
- B. Nausea with anorexia
- C. Alternating constipation and diarrhea
- D. Vomiting for over 48 hours
Correct Answer: A
Rationale: Severe diarrhea is the only problem listed that can lead to metabolic acidosis if untreated.
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Laboratory Reference Ranges
Glucose (random)
71-200 mg/dL
(3.9-11.1 mmol/L)
The student nurse completes a clinical rotation in the emergency department. The instructor knows the student is able to prioritize care appropriately when the student visits which client first?
- A. 9 year-old crying with pain and swelling of the left ankle after a popping sound while playing soccer
- B. 29-year-old with neck swelling and increased pain 2 days after thyroidectomy
- C. 43-year-old with blood glucose of 423 mg/dL (23.5 mmol/L), dehydration, and trace ketones in urine
- D. 72-year-old who is incontinent with acute altered mental status and is yelling at staff
Correct Answer: B
Rationale: Neck swelling and pain post-thyroidectomy suggest possible hematoma or airway compromise, a life-threatening emergency requiring immediate assessment. Other conditions, while serious, are less immediately critical.
A nursing assistant comes to the LPN/LVN and complains that she has more residents to care for than another nursing assistant (NA). She has one more resident assigned to her than the other NA. However, the other NA has more total care residents than the complaining NA. How should the LPN/LVN handle this situation?
- A. Tell the complaining NA that this is the assignment
- B. Promise to give her an easier assignment tomorrow
- C. Discuss with her the needs of her assignment and help her organize her care
- D. Tell her that the other NA will help her as needed
Correct Answer: C
Rationale: Discussing needs and organizing care addresses the NA's concerns constructively, promoting teamwork and efficiency without dismissing or deferring.
The nurse is caring for a client with HIV. The nurse understands that which of the following are true regarding transmission-based precautions? Select all that apply.
- A. Donning an N95 respiratory mask decreases the risk of transmitting HIV
- B. Gown, gloves, and face shield are necessary for every client encounter
- C. Neutropenic precautions are implemented based on laboratory results
- D. The client's urine is a bodily fluid that can transmit HIV
- E. The nurse should perform hand hygiene before and after providing client care
Correct Answer: C,D,E
Rationale: Neutropenic precautions depend on lab results (e.g., low white blood cell count). Urine can transmit HIV if blood is present. Hand hygiene is standard for all encounters. N95 masks are for airborne diseases, not HIV. Full PPE isn't needed unless splashing of bodily fluids is likely.
Vital signs
Temperature 99.2 F (37.3 C)
Blood pressure 134/89 mm Hg
Heart rate 98/min
Respirations 19/min
Oz saturation (SpO) 99%
Sedation Awake, alert
A client reports 7 of 10 on the pain scale at 2300 and asks if it is too soon to receive 'another pain pill.' The nurse reviews the medication administration record. Which intervention should the nurse implement?
- A. Administer the hydrocodone/acetaminophen as prescribed
- B. Call the health care provider to request a prescription for a different analgesic
- C. Decrease the dose of hydrocodone/acetaminophen from 2 tablets to 1
- D. Prepare to administer naloxone
Correct Answer: A
Rationale: Pain rated 7/10 warrants administration of the prescribed analgesic if within the dosing interval. No indications suggest overdose (naloxone) or need for a different medication. Reducing the dose may inadequately manage pain.
The nurse is preparing to administer ear drops to an adult client. It would require follow-up if the nurse
- A. instills the ear drops at room temperature
- B. instills the ear drops by placing the dropper into the ear canal
- C. pulls the pinna of the client's ear up and back before instillation
- D. places a cotton ball loosely in the outermost auditory canal after instillation
Correct Answer: B
Rationale: Placing the dropper into the ear canal risks injury and contamination. Ear drops should be instilled by holding the dropper above the canal. Other actions are correct: room-temperature drops prevent discomfort, pulling the pinna straightens the canal, and a cotton ball retains the medication.