Nokea
The nurse is planning a staff development conference about the care of transgender clients. Which of the following information should the nurse include? Select all that apply.
- A. At the start of the interview, inquire about the client's preferred pronoun.'
- B. Utilize binary gender terms on healthcare documentation.'
- C. Transgender individuals feel a variance between gender and natal sex.'
- D. Clients who are transgender may be reluctant to seek healthcare.'
- E. Inquire about any current or future plans for hormone therapy.'
Correct Answer: A, C, D, E
Rationale: Inquiring about pronouns (A), recognizing gender variance (C), acknowledging healthcare reluctance (D), and discussing hormone therapy (E) are inclusive and relevant. Binary gender terms (B) are inappropriate, as they exclude non-binary identities.
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The nurse has been made aware of the following client situations. The nurse should initially follow up with the client who is
- A. receiving albuterol via a nebulizer and reports feeling 'nervous'.
- B. awaiting a home healthcare referral following total hip arthroplasty.
- C. six hours post-op from a hysterectomy and is reporting nausea.
- D. reporting that their arm is 'sleeping' after having a cast for a fracture applied three hours ago.
Correct Answer: D
Rationale: Numbness ('sleeping' arm) post-cast application (D) suggests possible compartment syndrome or nerve compression, a surgical emergency requiring immediate follow-up. Nervousness from albuterol (A) is expected, home health referral (B) is non-urgent, and post-op nausea (C) is common but less critical.
The registered nurse (RN) supervises a licensed practical/vocational nurse (LPN). Which statement by the LPN/VN requires follow-up by the RN?
- A. I bathed the client already this morning'
- B. I passed out letters and packages to the clients this morning.'
- C. The client refused his prescribed valproic acid, so I snuck it into his food.'
- D. I will be joining the clients with their games today in the day room.'
Correct Answer: C
Rationale: Hiding medication in food (C) is unethical, unsafe, and violates client autonomy, requiring immediate RN follow-up. Bathing (A), distributing mail (B), and joining games (D) are within the LPN’s scope and do not require intervention.
The charge nurse plans client care assignments for an unlicensed assistive personnel (UAP) and a licensed practical/vocational nurse (LPN/VN) in the medical-surgical unit. Which activity should the charge nurse delegate to the LPN/VN to maximize staff resources?
- A. Perform wound care and dressing changes
- B. Collect routine vital signs (VS)
- C. Turn all bedbound clients every two hours
- D. Ambulate clients with ambulation orders
Correct Answer: A
Rationale: Wound care and dressing changes (A) utilize the LPN/VN’s clinical skills, maximizing resources. Vital signs (B), turning (C), and ambulation (D) are within UAP scope, allowing the LPN/VN to focus on higher-skill tasks.
The nurse is planning client assignments in the mental health unit. Which task should the nurse delegate to the licensed practical/vocational nurse (LPN/VN)?
- A. conduct a suicide assessment on a newly admitted client
- B. administering prescribed lithium to a client with bipolar disorder
- C. leading a group therapy session for clients with depressive disorders
- D. monitoring a client who is talking on the phone to a family member
Correct Answer: B
Rationale: Administering prescribed lithium (B) is within the LPN’s scope, involving medication administration to a stable client. Suicide assessment (A) and group therapy (B) require RN expertise, and monitoring phone calls (C) is a UAP task, making these inappropriate for LPN delegation (D).
The nurse working on a medical-surgical unit has just received a change-of-shift report. The nurse should initially assess the client who is
- A. receiving treatment for chronic pulmonary emphysema with PaCO2 of 50 mm Hg.
- B. admitted with pulmonary tuberculosis (TB) and refuses their prescribed isoniazid.
- C. infected with Clostridium difficile, and is reporting dizziness.
- D. being treated for acute pyelonephritis and has a temperature of 101.8°F (38.7°C).
Correct Answer: C
Rationale: Dizziness with Clostridium difficile infection (C) suggests dehydration or electrolyte imbalance, which can lead to falls or cardiovascular instability, requiring immediate assessment. A PaCO2 of 50 mm Hg in chronic emphysema (A) is often a baseline finding, TB medication refusal (B) is concerning but not immediately life-threatening, and fever in pyelonephritis (D) is expected and less urgent than acute instability.