Nokea
The practical nurse and the charge nurse work together to assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat argumentative cellulitis. Which of the 4 room assignments is the best option for this client?
- A. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge
- B. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device
- C. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism
- D. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine
Correct Answer: A
Rationale: The postoperative client in Room 1 is stable and awaiting discharge, posing the least risk of complications or infection to the client with cellulitis. Other roommates have conditions (dementia, embolism, immunosuppression) that could complicate care or increase infection risk.
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The nurse practicing on a long-term care unit cares for a client with type 1 diabetes mellitus. Which action should the nurse assign to experienced unlicensed assistive personnel?
- A. Check the blood glucose before meals and report it to the nurse
- B. Instruct the client to cut toenails straight across and file any sharp edges
- C. Monitor the client for signs and symptoms of hypoglycemia
- D. Update the care plan to include client's preference for a nighttime diabetic snack
Correct Answer: A
Rationale: Checking blood glucose and reporting results is within UAP scope if trained. Teaching, monitoring for hypoglycemia, and updating care plans require nursing judgment and are outside UAP scope.
A staff nurse complains to the nurse manager that an unlicensed assistive personnel (UAP) consistently leaves the work area untidy and does not restock supplies. The best initial response by the nurse manager is which of these statements?
- A. I will arrange for a conference with you and the UAP within the next week
- B. I can assure you that I will look into the matter
- C. I would like for you to approach the UAP about the problem the next time it occurs
- D. I will add this concern to the agenda for the next unit meeting
Correct Answer: C
Rationale: Helping staff manage conflict is part of the manager's role. It is appropriate to urge the nurse to confront the other staff member to work out problems without a manager's intervention when possible.
The licensed practical nurse is working with a registered nurse to care for a client who has just returned to the cardiac unit after having a percutaneous coronary intervention. Which actions assigned by the registered nurse should the practical nurse question as outside of the practical nurse's scope of practice? Select all that apply.
- A. Administering oral pain medication if client reports low back pain
- B. Checking for bleeding at the catheter insertion site every 15 minutes
- C. Performing post-procedure vital sign measurements
- D. Reinforcing instructions to keep the involved extremity straight
- E. Reviewing ECG for dysrhythmias
Correct Answer: E
Rationale: Reviewing ECGs for dysrhythmias requires advanced assessment skills beyond LPN scope. Administering medication, checking for bleeding, taking vital signs, and reinforcing instructions are within LPN scope if trained.
The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?
- A. Client who had a foot amputation today reporting left shoulder pain radiating down the arm
- B. Client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain
- C. Client who has multiple myeloma reporting deep pelvic pain after walking down the hall
- D. Client who has sickle cell disease reporting severe pain in the arms and upper back
Correct Answer: A
Rationale: Shoulder pain radiating down the arm post-amputation suggests a possible cardiac event (e.g., angina), a life-threatening condition requiring immediate assessment. Other pains, while severe, are more likely related to known conditions.
The nurse is caring for a client with Cushing's syndrome. The nurse should carefully assess the client for signs of:
- A. Hypoglycemia
- B. Infection
- C. Hypovolemia
- D. Hyperinsulinemia
Correct Answer: B
Rationale: Cushing's syndrome causes immunosuppression, increasing infection risk . Hypoglycemia , hypovolemia , and hyperinsulinemia are not primary concerns.