Nokea
The nursing care plan for the client with dehydration includes interventions for oral health. Which interventions are within the scope of practice for the LPN/LVN being supervised by the nurse? (Choose all that apply.)
- A. Remind client to avoid commercial mouthwashes.
- B. Encourage mouth rinsing with warm saline.
- C. Assess lips,tongue and mucous membranes.
- D. Provide mouth care every 2 hours while client is awake.
Correct Answer: A
Rationale: All listed interventions are appropriate and within the LPN/LVN’s scope of practice under supervision. They contribute to maintaining oral health and hydration in dehydrated clients.
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A patient who received spinal anesthesia four hours ago during surgery is transferred to the surgical unit and, after 90 minutes, now reports severe incisional pain. The patient's blood pressure is 170/90 mmHg, pulse is 108 beats/min, temperature is 99oF (37.2oC), and respirations are 30 breaths/min. The patient's skin is pale, and the surgical dressing is dry and intact. The most appropriate nursing intervention is to
- A. medicate the patient for pain.
- B. place the patient in a high Fowler position and administer oxygen.
- C. place the patient in a reverse Trendelenburg position and open the IV line.
- D. report the findings to the provider.
Correct Answer: D
Rationale: The nurse should report these findings to the provider because the patient may be experiencing complications such as hypertension or hypovolemia.
What should the conversation focus on regarding Mr. Puff’s concern about sexual intercourse?
- A. Improving his self-esteem
- B. The role that his wife plays as a supportive partner
- C. Avoiding further pulmonary damage
- D. Alternative positions for intercourse
Correct Answer: D
Rationale: Modifying positions reduces exertion and breathlessness.
A healthcare professional is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the healthcare professional expect?
- A. Bradycardia
- B. Bradypnea
- C. Lethargy
- D. Intercostal retractions
Correct Answer: D
Rationale: The correct answer is D: Intercostal retractions. In postoperative atelectasis, there is a collapse of lung tissue leading to decreased oxygen exchange and hypoxia. Intercostal retractions indicate increased work of breathing as the body tries to compensate for the decreased lung function. Bradycardia and bradypnea are not typically associated with hypoxia but rather with decreased oxygen delivery to tissues. Lethargy is a nonspecific symptom and may not directly correlate with hypoxia in this scenario.
Match the following types of pain in the left column with a category of pain from the upper right column and an example of the source of the pain from the lower right column.
- A. Pain from loss of afferent input
- B. Pain persisting from sympathetic nervous system (SNS) activity
- C. Pain caused by dysfunction in the central nervous system (CNS)
- D. Pain arising from muscles and bones; localized or diffuse and radiating
Correct Answer: D
Rationale: Pain felt along the distribution of peripheral nerve(s) from nerve damage
Mr. and Mrs. Smith took part in a community health screening. What does a positive reaction to the standard intermediate strength PPD mean?
- A. Have active tuberculosis
- B. Are “carriers” of tuberculosis
- C. Have already transmitted tuberculosis to their children
- D. Have been exposed to active tuberculosis
Correct Answer: D
Rationale: A positive PPD test indicates past exposure to Mycobacterium tuberculosis but does not confirm active disease.