Nokea
The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full-weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the nurse reinforce when teaching the client?
- A. 2-point gait
- B. 3-point gait
- C. 4-point gait
- D. 5-point gait
Correct Answer: A
Rationale: The 2-point gait mimics normal walking, alternating crutch and opposite leg, suitable for full-weight bearing. 3-point is for non-weight bearing, 4-point is slower, and 5-point does not exist.
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The client is scheduled for a glucose tolerance test. Place in ordered response the correct sequence for performance of this test.
- A. Instruct the client to drink a 75 gm glucose solution.
- B. Tell the client to eat a high carbohydrate diet for three days prior to the exam.
- C. Instruct the client to remain NPO after midnight.
- D. Obtain a fasting blood glucose level.
- E. Obtain a two-hour post-prandial glucose level.
Correct Answer: B,C,D,A,E
Rationale: When placing in chronological order, the nurse should: tell the client to increase the amount of carbohydrates for three days prior to the exam; instruct the client to remain NPO after midnight the day of the exam; obtain a fasting blood glucose level; instruct the client to drink a 75 gm glucose solution; and obtain a two-hour post-prandial glucose level. The candidate is asked to place answers in a logical sequence. Think about the natural order of the question.
The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?
- A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.
- B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.
- C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.
- D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.
Correct Answer: B
Rationale: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.
The father of an 8 month-old infant asks the nurse if his child's vocalizations are normal for his age. Which of the following would the nurse expect at this age?
- A. Cooing
- B. Imitation of sounds
- C. Throaty sounds
- D. Laughter
Correct Answer: B
Rationale: Imitation of sounds. Eight-month-olds typically imitate sounds like 'da-da' as part of language development.
The nurse is caring for a postoperative client who is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client can be roused and responds to verbal commands. One hour later, the client is again difficult to rouse, with minimal response to physical stimuli. Which actions does the nurse anticipate? Select all that apply.
- A. Administration of oxygen
- B. Administration of a 2nd dose of naloxone
- C. Discontinuation of pain medication
- D. Initiation of a rapid response or code team
- E. Monitoring of respiratory rate
Correct Answer: A,B,E
Rationale: Recurrent unresponsiveness suggests opioid re-narcotization, requiring oxygen, a second naloxone dose, and respiratory monitoring. Discontinuing pain medication is premature, and rapid response is not yet indicated.
The nurse is caring for an 8-month-old client with suspected acute otitis media. Which of the following findings would be consistent with the condition? Select all that apply.
- A. Frequent pulling on the affected ear
- B. Purulent drainage from the affected ear
- C. Refusal to eat
- D. Restlessness and irritability
- E. Retracted tympanic membranes
Correct Answer: A,C,D
Rationale: Ear pulling, refusal to eat, and irritability are common in otitis media due to pain and inflammation. Purulent drainage is less common unless the eardrum ruptures, and tympanic membranes are typically bulging, not retracted.