Nokea
Twenty minutes after starting a heat application, the client mentions that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN?
- A. That indicates you have derived the maximum benefit, and the heat can be removed.
- B. Your blood vessels are dilating and removing the heat from the site.
- C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
- D. The body's receptors adapt over time as they are exposed to heat.
Correct Answer: D
Rationale: Choice D is the correct response. The body's receptors adapt to the heat over time, which can explain why the client no longer perceives the warmth from the heating pad. This phenomenon is known as thermal adaptation. Choices A, B, and C are incorrect. Choice A is inaccurate because the client not feeling the warmth does not necessarily mean they have derived the maximum benefit. Choice B incorrectly states that blood vessels dilating remove heat, which is not accurate. Choice C suggests increasing the temperature when the pad no longer feels warm, which could potentially lead to burns or discomfort for the client.
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A nurse has an order to remove sutures from a client. After retrieving the suture remover kit and applying sterile gloves, which of the following actions should the nurse take next?
- A. Clean sutures along the incision site.
- B. Grasp the knot of the sutures with forceps.
- C. Cut the sutures close to the skin on one side.
- D. Pull out the sutures with forceps in one piece.
Correct Answer: A
Rationale: The correct action for the nurse to take next after preparing the suture remover kit and applying sterile gloves is to clean sutures along the incision site. This step is crucial in preventing infection, which is the greatest risk to the client during suture removal. Cleaning the site helps minimize the risk of introducing microorganisms into the incision, reducing the chances of infection. Grasping at the knot of the sutures with forceps (Choice B) is incorrect as it does not address the need to clean the incision. Cutting the sutures close to the skin on one side (Choice C) or pulling out the sutures with forceps in one piece (Choice D) without proper cleaning can increase the risk of infection and should not be the next step in the process of suture removal.
The healthcare provider is reviewing the plan of care for a client with a newly placed colostomy. Which outcome would indicate effective client teaching?
- A. Client demonstrates how to irrigate the colostomy.
- B. Client verbalizes understanding of dietary changes.
- C. Client performs ostomy care independently.
- D. Client expresses feelings about the impact of the colostomy.
Correct Answer: C
Rationale: The correct answer is C because effective teaching is demonstrated when the client can independently perform ostomy care. This indicates that the client has understood and retained the information provided during teaching. Choices A, B, and D are incorrect because demonstrating how to irrigate the colostomy, verbalizing understanding of dietary changes, and expressing feelings about the impact of the colostomy are important aspects of care but do not directly reflect the client's ability to apply the taught information in a practical setting.
A client in an oncology clinic is being assessed by a nurse while undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress?
- A. I keep having nightmares about my upcoming surgery.
- B. I feel more energetic than I did before.
- C. I have been making plans for the future.
- D. I am looking forward to starting my new treatment.
Correct Answer: A
Rationale: Choice A is the correct answer as nightmares about upcoming surgery indicate psychological distress commonly associated with fears, anxiety, and stress related to the treatment. Choices B, C, and D suggest positive emotions and proactive behaviors that are not typical signs of psychological distress in this context. Feeling more energetic, making future plans, and looking forward to treatment are generally positive indicators of coping and adjustment to the situation.
A client requires bed rest and has a prescription for anti-embolic stockings. Which of the following actions should the nurse take?
- A. Apply the stockings with the creases on the front of the leg.
- B. Apply the stockings while the client's legs are in a dependent position.
- C. Remove the stockings at least once per shift.
- D. Remove the stockings while the client is sitting in a reclining chair.
Correct Answer: C
Rationale: The correct action for the nurse to take is to remove the anti-embolic stockings at least once per shift. This is essential to assess the client's circulation and skin integrity. Option A is incorrect because the stockings should be applied without creases to ensure proper compression. Option B is incorrect as the stockings should be applied when the client's legs are elevated, not in a dependent position. Option D is incorrect as removing the stockings while the client is sitting in a reclining chair is not necessary and does not provide the appropriate assessment opportunity.
UAP has lowered the head of the bed to change the linens for a client who is bedridden. Which observation...most immediate intervention by the nurse?
- A. A feeding is infusing at 40 mL/hr through an enteral feeding tube.
- B. The urine meter attached to the urinary drainage bag is completely full.
- C. There is a large dependent loop in the client's urinary drainage tubing.
- D. Purulent drainage is present around the insertion site of the feeding tube.
Correct Answer: D
Rationale: The correct answer is D. Purulent drainage around the insertion site of the feeding tube indicates an infection, which requires immediate attention. This may be a sign of a serious complication that needs prompt nursing intervention to prevent further complications or deterioration in the client's condition. Choices A, B, and C do not indicate an immediate threat to the client's health. While option A highlights the infusion rate of the feeding, it does not pose an immediate risk compared to the presence of purulent drainage indicating infection.