Nokea
The nurse observes a client self-administering nasal fluticasone. Which observation would require the practical nurse to intervene and reinforce the instructions provided by the registered nurse?
- A. A sitting position is assumed as the head is bowed slightly forward
- B. The client points the spray tip toward the nasal septum during instillation
- C. The nasal spray tip is inserted into the nostril as the other nostril is occluded
- D. While administering the medication, the client inhales deeply through the nose
Correct Answer: B
Rationale: Pointing fluticasone toward the nasal septum risks irritation or bleeding; it should be aimed laterally. Sitting with head forward, occluding the other nostril, and inhaling deeply are correct administration techniques.
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The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
- A. Skin irritation
- B. Drug tolerance
- C. Severe headaches
- D. Postural hypotension
Correct Answer: B
Rationale: Drug tolerance. Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.
A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
- A. Transparent film dressing
- B. Wet dressing with debridement granules
- C. Wet to dry with hydrogen peroxide
- D. Moist saline dressing
Correct Answer: D
Rationale: Moist saline dressing. A stage III pressure ulcer with granulation tissue requires a moist environment to promote healing.
An 85-year-old woman is hospitalized with a fractured hip. She complains to the LPN/LVN that she feels something is wrong and her chest hurts. The nurse notes the client has tachypnea. What should the nurse do immediately?
- A. Administer oxygen
- B. Take vital signs
- C. Elevate the head of the bed
- D. Give aspirin
Correct Answer: B
Rationale: Chest pain and tachypnea suggest a possible pulmonary embolism post-hip fracture; taking vital signs provides critical data for immediate assessment.
The nurse is contributing to a staff education program about assessing the urinary system. Which statement by a nurse would indicate a correct understanding of the program?
- A. The bladder should be nontender and nonpalpable when it is empty
- B. Dark brown urine may indicate that the client has a urinary tract infection
- C. I should be able to palpate both kidneys regardless of the client’s abdominal girth
- D. I will assess for tenderness of the kidneys by performing blunt percussion over the client’s lower abdomen
Correct Answer: A
Rationale: An empty bladder is nontender and nonpalpable, indicating correct understanding. Dark brown urine suggests dehydration or other issues, not UTI; kidneys are not always palpable; and percussion is over the costovertebral angle, not lower abdomen.
The nurse is assisting with an education conference for graduate nurses about infant CPR. Which of the following statements are appropriate to include in the teaching? Select all that apply.
- A. A single rescuer responding to an unwitnessed infant arrest should perform 2 minutes of CPR before retrieving a defibrillator
- B. Depth of chest compressions for infants should be half the depth of the anterior-posterior chest diameter
- C. Rescuers should place the heel of one hand on the lower sternum when delivering chest compressions to infants
- D. The ratio of chest compressions to breaths during CPR by a single rescuer is 15:2 for infants
- E. You should assess the infant’s brachial pulse for no longer than 10 seconds
Correct Answer: A,E
Rationale: Two minutes of CPR before defibrillator retrieval and assessing the brachial pulse for ≤10 seconds align with infant CPR guidelines. Compression depth is about one-third the chest, two fingers are used, and the ratio is 30:2 for a single rescuer.