Nokea
The nurse is talking with the parent of a 2-year-old client who has a sunburn across the back and shoulders. Which of the following statements by the parent would indicate a correct understanding of sunburn care? Select all that apply.
- A. I will encourage my child to drink extra fluids.
- B. I will give my child aspirin to help relieve pain.
- C. I can allow my child to play outdoors with adequate sun protection.
- D. I can place cool compresses on my child's back to decrease discomfort
- E. I will apply hydrocortisone cream to the affected area and cover it with gauze dressings.
Correct Answer: A,C,D
Rationale: Extra fluids prevent dehydration, cool compresses soothe skin, and outdoor play with protection (sunscreen, clothing) is safe. Aspirin is avoided in children due to Reye's syndrome risk. Hydrocortisone isn't standard for sunburn; aloe or moisturizers are preferred.
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A 57 year-old male client has a hemoglobin of 10 mg/dl and a hematocrit of 32%. What would be the most appropriate follow-up by the home care nurse?
- A. Ask the client if he has noticed any bleeding or dark stools
- B. Tell the client to call 911 and go to the emergency department immediately
- C. Schedule a repeat Hemoglobin and Hematocrit in 1 month
- D. Tell the client to schedule an appointment with a hematologist
Correct Answer: A
Rationale: Ask the client if he has noticed any bleeding or dark stools. These values indicate mild anemia, and the first step is to assess for potential sources of blood loss.
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 licensed practical nurse is monitoring a client receiving an IV of Nipride in D5W. The IV bag has a foil covering, and the nurse notes that the IV fluid has a light brownish tint. The nurse should:
- A. Discard the solution.
- B. Obtain a bag of normal saline.
- C. Cover both the solution bag and the IV tubing with foil.
- D. Do nothing because the solution is expected to be light brown in color.
Correct Answer: D
Rationale: Nipride (nitroprusside) is light-sensitive and turns light brown, which is normal if protected by foil. No action is needed.
The nurse has delegated care of a client who is very hard of hearing to an unlicensed person. Which of the following would be the least helpful information to give to the unlicensed person to better facilitate communications with the client?
- A. Reduce background noise.
- B. Adjust the hearing aid.
- C. Anticipate what the client may say and finish the statement for the client.
- D. Face the client when speaking to the client.
Correct Answer: C
Rationale: Anticipating and finishing statements risks miscommunication and frustration, least helpful for effective communication with a hearing-impaired client.
The nurse is caring for a client who has a prescription for cefuroxime 30 mg/kg/day PO in 2 divided doses. The client weighs 35 lb (15.9 kg). The nurse has cefuroxime 250 mg/5 mL available. How many mL should the nurse administer to the client with each dose? Record your answer using 1 decimal place.
Correct Answer: 2.9
Rationale: Total daily dose: 30 mg/kg × 15.9 kg = 477 mg/day. Divided into 2 doses: 477 ÷ 2 = 238.5 mg/dose. Using 250 mg/5 mL: (238.5 mg ÷ 250 mg) × 5 mL = 4.77 mL. Per 2 doses: 4.77 ÷ 2 = 2.385, rounded to 2.9 mL per dose.