Nokea
The nurse is reviewing the plan of care for multiple clients receiving opioids for pain management. Which client has the greatest risk for respiratory depression?
- A. 20-year-old client with chronic bronchitis who is receiving inhaled albuterol therapy every 4 hours
- B. 30-year-old client with opioid use disorder who had rotator cuff repair surgery this morning
- C. 50-year-old client with sleep apnea and left foot cellulitis who is scheduled for a bone scan later today
- D. 70-year-old client with chronic obstructive pulmonary disease who had knee replacement this morning
Correct Answer: D
Rationale: The 70-year-old with COPD is at highest risk for opioid-induced respiratory depression due to age-related reduced lung capacity and COPD-related impaired gas exchange. Chronic bronchitis and opioid use disorder increase risk but are less severe in this context.
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Laboratory reference ranges
Potassium3.5-5.0 mEq/L(3.5-5.0 mmol/L)
INRNormal: 0.8-1.1Therapeutic: 1.5-4.0
The nurse recognizes which of the following factors as possibly contributing to a sentinel event?
- A. Administered warfarin to a client with an INR of 6.0
- B. Administered flumazenil to a client who overdosed on lorazepam
- C. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
- D. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
Correct Answer: A
Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.
The nurse approaches a 4-year-old boy to administer a medication. The child has no identification armband. Which action is most appropriate?
- A. Check the room and bed number the child is in with the room and bed number on the medication order and administer the medication if they agree
- B. Ask the child what his name is before administering the medication
- C. Ask the child if his name is George (the name on the medication order) and administer the medication if the child says that is his name
- D. Ask the adults at the bedside what the child's name is and administer the medication if the adults verify the name of the child
Correct Answer: D
Rationale: Verifying the child's identity with adults at the bedside ensures safety, as children may not reliably confirm their own identity, and room/bed numbers are not sufficient for identification.
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 is being evaluated for carpal tunnel syndrome. The nurse is observed asking the client to place the backs of her hands together and flex them at the same time. Which assessment is the nurse performing?
- A. Phalen's maneuver
- B. Tinel's sign
- C. Kernig's
- D. Brudzinski's
Correct Answer: A
Rationale: Phalen's maneuver involves flexing the wrists with the backs of the hands together to assess for carpal tunnel syndrome, as it may reproduce symptoms. Tinel's sign involves tapping over the median nerve. Kernig's and Brudzinski's are tests for meningitis, not carpal tunnel syndrome.
A client involved in a motor vehicle accident has a 4-inch laceration on her left lower leg. Which finding is consistent with an acute inflammatory reaction?
- A. Increased pain caused by the release of histamine
- B. Blanching of the skin proximal to the laceration
- C. A decrease in the white blood count
- D. Granulation of tissue at the edges of the laceration
Correct Answer: A
Rationale: Histamine release during acute inflammation causes pain and vasodilation. Blanching is not typical, white blood count increases, and granulation occurs later.