Nokea
The nurse is monitoring a client with suspected pulmonary tuberculosis. Which characteristic signs and symptoms does the nurse expect? Select all that apply.
- A. Dysuria
- B. Jaundice
- C. Low back pain
- D. Night sweats
- E. Weight loss
- F. Purulent or blood-tinged sputum
Correct Answer: D,E,F
Rationale: Night sweats, weight loss, and purulent/blood-tinged sputum are hallmark symptoms of pulmonary tuberculosis.
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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.
Which of the following is not considered one of the five rights of medication administration?
- A. client
- B. drug
- C. dose
- D. routine
Correct Answer: D
Rationale: Dose, client, drug, route and time are considered the five rights of medication.
The nurse is preparing to administer sumatriptan to a client with a migraine headache. Which of the following findings would require follow-up prior to administering the medication?
- A. BMI of 34 kg/m recorded during today's examination
- B. past medical history of uncontrolled hypertension
- C. takes alprazolam as prescribed for anxiety
- D. BUN of 12 mg/dL (4.28 mmol/L)
Correct Answer: B
Rationale: Sumatriptan is contraindicated in uncontrolled hypertension due to the risk of cardiovascular events.
An adult who recently had an amputation has an above-the-knee prosthesis. Which nursing action will do the most to help the client adjust to the prosthesis?
- A. Adjust the prosthesis for the client.
- B. Offer the client a cane or a walker for ease of movement.
- C. Place an 'at risk for fall' sign on the client's door.
- D. Allow the client to manage his own care.
Correct Answer: D
Rationale: Allowing self-management fosters independence and confidence with the prosthesis, promoting adjustment.
The nurse is talking about diaper changes with a client who is 48 hours postpartum. The client states, 'I cannot change my baby's diaper as well as you can. Will you change it for me?' Which of the following responses would be appropriate for the nurse to make?
- A. Changing your baby's diaper now is important for the bonding process.
- B. I will stay at your bedside and watch while you change your baby's diaper.
- C. It is more important for you to take care of yourself now, so I will change your baby's diaper.
- D. It is time that you change your baby's diaper because you will have to do it by yourself after discharge.
Correct Answer: B
Rationale: Supporting the client while they change the diaper builds confidence and promotes independence.