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What intervention is most important for the LPN/LVN to implement for a male client experiencing urinary retention?
- A. Apply a condom catheter.
- B. Apply a skin protectant.
- C. Encourage increased fluid intake.
- D. Assess for bladder distention.
Correct Answer: D
Rationale: The most important intervention for the LPN/LVN to implement for a male client experiencing urinary retention is to assess for bladder distention. This assessment is crucial as it helps identify the underlying cause of urinary retention, such as bladder distention or obstruction. By assessing the bladder, the LPN/LVN can determine the appropriate interventions needed, such as catheterization, medication administration, or further evaluation by the healthcare provider. Applying a condom catheter (Choice A) is more suitable for urinary incontinence, not retention. Applying a skin protectant (Choice B) is typically done to prevent skin breakdown in incontinent clients. Encouraging increased fluid intake (Choice C) may be beneficial for some urinary issues but is not the priority intervention for urinary retention.
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The nurse is caring for a client with a pressure ulcer on the sacrum. Which action should the LPN/LVN take to prevent further skin breakdown?
- A. Apply a hydrocolloid dressing to the ulcer.
- B. Reposition the client every 2 hours.
- C. Use a donut-shaped cushion when the client is sitting.
- D. Massage the area around the ulcer to promote circulation.
Correct Answer: B
Rationale: Repositioning the client every 2 hours is the most appropriate action to prevent further skin breakdown in a client with a pressure ulcer on the sacrum. This practice helps relieve pressure on the affected area, promoting circulation and reducing the risk of tissue damage. Applying a hydrocolloid dressing (Choice A) may be beneficial for wound healing but is not the initial preventive measure. Using a donut-shaped cushion (Choice C) can actually increase pressure on the sacrum and worsen the condition. Massaging the area around the ulcer (Choice D) can further damage delicate skin and tissues, leading to more harm instead of prevention.
When preparing for a change of shift, which document or tools should a healthcare provider use to communicate?
- A. SBAR
- B. SOAP
- C. PIE
- D. DAR
Correct Answer: A
Rationale: The correct answer is A: SBAR (Situation, Background, Assessment, Recommendation) is a structured method for communicating information during shift changes. SBAR provides a clear and concise way for healthcare providers to communicate important details about a patient's condition, ensuring that essential information is effectively transferred between providers. Choice B, SOAP (Subjective, Objective, Assessment, Plan), is a method primarily used for documentation in patient charts, not for shift change communication. Choice C, PIE (Problem, Intervention, Evaluation), is a nursing process format for organizing nursing care that focuses on individualized patient care plans, not shift handoff communication. Choice D, DAR (Data, Action, Response), is not a standard format for provider-to-provider handoff communication and is less commonly used in healthcare settings compared to SBAR.
A client is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?
- A. Monitor the client for pain in the suprapubic region.
- B. Ensure the client is free of metal objects.
- C. Administer 240 mL (8 oz) of oral contrast before the procedure.
- D. Assist the client with a bowel cleansing.
Correct Answer: B
Rationale: The correct action for the nurse to include before an intravenous pyelogram is ensuring the client is free of metal objects. Metal objects can interfere with the imaging procedure and may need to be removed to prevent artifacts. Monitoring for pain in the suprapubic region (choice A) is not directly related to the procedure and is not a standard pre-procedure action. Administering oral contrast (choice C) is more common for other imaging studies like a CT scan, not an intravenous pyelogram. Assisting with a bowel cleansing (choice D) is not typically required before an intravenous pyelogram.
A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give to the client?
- A. We need to document the exact medication you were taking because you might be allergic to it.
- B. You should take a different type of antibiotic this time.
- C. A rash is a common reaction and is not usually concerning.
- D. You can take the same antibiotic again if needed.
Correct Answer: A
Rationale: The nurse should advise the client to document the exact medication taken to identify potential allergies and prevent adverse reactions. This is important as the client developed a rash previously while taking an antibiotic, indicating a possible allergic reaction. Choice B is not appropriate as switching antibiotics without proper evaluation can be risky. Choice C is incorrect as rashes should not be dismissed without further investigation, especially in the context of taking medication. Choice D is also not recommended as re-taking the same antibiotic without clarifying the allergic reaction can lead to a potentially severe outcome.
When administering an otic medication to an older adult client, which action should the nurse take to ensure that the medication reaches the inner ear?
- A. Press gently on the tragus of the client's ear
- B. Pack a small piece of cotton deep into the client's ear canal
- C. Move the client's auricle down and back toward their head
- D. Tilt the client's head backward for 5 minutes
Correct Answer: A
Rationale: The correct action to ensure that otic medication reaches the inner ear is to press gently on the tragus. The tragus is a small cartilaginous projection in front of the ear canal. Pressing on it helps to straighten the ear canal, allowing the medication to reach the inner ear. Packing cotton or moving the auricle can obstruct the ear canal and prevent proper medication delivery. Tilting the client's head backward is not necessary and may not facilitate the medication reaching the inner ear as effectively as pressing on the tragus.