Nokea
To provide optimal continuity of care, the nurse should do all of the following except:
- A. document current functional status.
- B. have the physician phone a report to the receiving facility.
- C. copy appropriate parts of the medical record for transport to the receiving facility.
- D. phone a report to the facility.
Correct Answer: B
Rationale: It is the nurse's responsibility to communicate the client's condition and care plan to the receiving facility to support continuity of care. Documentation of the client's baseline functional status is important for the receiving facility to work with in further goal setting. A copy of select portions of the medical record (according to facility policy) is another form of communication and supports continuity. A physician might be asked to be involved if there are specific medical needs or orders that she believe are important, but is generally not involved.
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While performing a physical assessment on a 6-month-old infant, the nurse observes head lag. Which of the following nursing actions should the nurse perform first?
- A. Ask the parents to allow the infant to lay on her stomach to promote muscle development
- B. Notify the physician because a developmental or neurological evaluation is indicated
- C. Document the findings as normal in the nurse's notes
- D. Explain to the parents that their child is likely to be mentally retarded
Correct Answer: B
Rationale: Persistent head lag at 6 months suggests developmental or neurological issues, warranting immediate physician referral for evaluation.
Which of the following statements, if made by the parents of a newborn, does not indicate a need for further teaching about cord care?
- A. I should put alcohol on my baby's cord 3-4 times a day.'
- B. I should put the baby's diaper on so that it covers the cord.'
- C. I should call the physician if the cord becomes dark.'
- D. I should wash my hands before and after I take care of the cord.'
Correct Answer: D
Rationale: Parents should be taught to wash their hands before and after providing cord care. This prevents transferring pathogens to and from the cord. Folding the diaper below the cord exposes the cord to air and allows for drying. It also prevents wet or soiled diapers from coming into contact with the cord. Current recommendations include cleaning the area around the cord 3-4 times a day with a cotton swab but do not include putting alcohol or other antimicrobials on the cord. It is normal for the cord to turn dark as it dries.
The nurse is caring for a client awaiting test results on a biopsy. The client is unconscious, and the physician informs the client's spouse that the biopsy came back positive for cancer. The spouse asks the nurse if they will not share this news with the client because they would prefer the client be unaware of the diagnosis. Which of the following responses is most appropriate?
- A. I will have a psychiatrist confirm that the news will cause negative effects, and if so, I will comply with your request.'
- B. For ethical reasons, I am unable to withhold this information from the client.'
- C. You will need to sign paperwork stating you are accepting the risk of not sharing this with the client.'
- D. You must have a durable power of attorney for health care advanced directive in place before I can consider this request.'
Correct Answer: B
Rationale: The ethical principle of veracity requires that the nurse is truthful with the client and does not withhold information even if it is requested by the family.
In what order should the LPN see the following clients? A. a 72-year-old client with pneumonia asking to order her dinner.,B. a 23-year-old client with left arm fracture after an MVA complaining of 6 out of 10 pain in his arm.,C. a 53-year-old client with lower leg swelling complaining of sudden onset headache and blurry vision. ,D. a 47-year-old client requesting more information regarding her surgery scheduled in three hours
- A. A) A, D, B, C
- B. B) C, B, D, A
- C. C) D, C, B, A
- D. D) B, C, A, D
Correct Answer: B
Rationale: Prioritizing client care is a critical skill to learn as a LPN. The 53-year-old is at highest risk for serious healthcare complications and should be seen first. The 23-year-old's pain should be addressed second, prior to answering questions about the 47-year-old's surgery. Finally, the LPN should address the needs of the 72-year-old client.
Which of the following strategies should the nurse include when planning care for children of migrant workers?
- A. Delay immunization because of acute illness
- B. Provide parents with copies of medical records
- C. Schedule preventive services at acute illness visits
- D. Stress the importance of using one primary care provider
Correct Answer: B
Rationale: Providing medical records ensures continuity of care for migrant children, who frequently relocate, supporting consistent health management.