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The nurse is working with families who have been displaced by a fire in an apartment complex. What is the priority intervention during the initial assessment?
- A. Provide a liaison to meet housing needs.
- B. Attentively listen when clients describe their feelings.
- C. Offer nurturing support for clients who are confused by the events.
- D. Provide structure for clients exhibiting moderate to severe anxiety.
Correct Answer: A
Rationale: The correct answer is to provide a liaison to meet housing needs. In the initial assessment after a disaster like a fire, ensuring basic needs such as housing, clothing, and food are met is the priority. Once the physical needs are addressed, the nurse can then focus on assisting clients in managing the psychological effects of loss. Choices B, C, and D are not the priority during the initial assessment as addressing housing needs should come first to provide a sense of stability and security for the affected families.
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What should the charge nurse do after overhearing the patient care assistant speaking harshly to the client with dementia?
- A. Change the patient care assistant's assignment
- B. Explore the interaction with the patient care assistant
- C. Discuss the matter with the client's family
- D. Initiate a group session with the patient care assistant
Correct Answer: B
Rationale: The best action for the charge nurse to take is to explore the interaction with the patient care assistant. This step allows for clarification of the situation and direct addressing of the issue. Changing the patient care assistant's assignment (choice A) might be necessary, but understanding the situation should come first. Discussing the matter with the client's family (choice C) as an initial step could escalate the situation. Initiating a group session with the patient care assistant (choice D) could be considered later as a preventive measure to avoid similar incidents in the future.
Which client can best be assigned to the newly licensed practical nurse?
- A. The client receiving chemotherapy
- B. The client post-coronary bypass
- C. The client with a TURP
- D. The client with diverticulitis
Correct Answer: D
Rationale: The best client to assign to the newly licensed nurse is the most stable client. In this case, the client with diverticulitis is the most stable among the options provided. Clients receiving chemotherapy and those post-coronary bypass require specialized care and attention, making them unsuitable for a newly licensed nurse. The client with a TURP may be at risk of bleeding, needing a nurse experienced in managing such complications. Therefore, the client with diverticulitis is the most appropriate choice for the newly licensed practical nurse.
The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?
- A. The graduate places the client in a supine position to read the manometer.
- B. The graduate turns the stop-cock to the off position from the IV fluid to the client.
- C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
- D. The graduate notes the level at the top of the meniscus.
Correct Answer: C
Rationale: The correct answer is C because the client should breathe normally during a central venous pressure monitor reading. Placing the client in a supine position (Choice A) is correct if the client can tolerate it. Turning the stop-cock off (Choice B) and noting the level at the top of the meniscus (Choice D) are also correct actions during CVP monitoring. Instructing the client to perform the Valsalva maneuver is incorrect as it can artificially alter the CVP reading, indicating a need for further teaching.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
- A. Continue monitoring the vital signs
- B. Contact the physician
- C. Ask the client how they feel
- D. Ask the LPN to continue post-op care
Correct Answer: B
Rationale: The priority action for the nurse is to contact the physician immediately due to the client's abnormal vital signs. A blood pressure of 90/50, pulse of 132, and respirations of 30 indicate instability and require prompt medical attention. Continuing to monitor vital signs, as in choice A, may lead to a delay in necessary interventions. Asking the client how they feel, as in choice C, provides subjective data and does not address the urgent need for medical intervention. Involving the LPN, as in choice D, is not appropriate in this critical situation where the client's condition is unstable and requires immediate physician assessment and intervention.
The LPN is teaching a first-time mother about breastfeeding her newborn. Which statement, if made by the mother, would reflect that the teaching had been successful?
- A. "My baby should be having at least 4-6 wet diapers a day until 1 month."?
- B. "It's nice that breastfed babies eat a bit less than formula-fed babies."?
- C. "My baby should be nursing 8-12 times a day during this period."?
- D. "I'm a little nervous about my milk coming in tomorrow. I've heard it's uncomfortable."?
Correct Answer: C
Rationale: The correct answer is, '"My baby should be nursing 8-12 times a day during this period."?' This statement indicates successful teaching because newborns should nurse 8-12 times during the newborn period to ensure they receive adequate nutrition and establish a good milk supply. This frequency helps in meeting the baby's demands for growth and development.
Choice A is incorrect because while it mentions the appropriate number of wet diapers a day once the mother's milk comes in, it does not reflect successful teaching about breastfeeding frequency.
Choice B is incorrect because it discusses feeding amounts in comparison to formula-fed babies, which is not a direct indicator of successful breastfeeding teaching.
Choice D is incorrect because it focuses on the mother's concerns about milk coming in, not on understanding the feeding frequency needed for the newborn.