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When a client has a chest drainage system in place, where should the system be placed?
- A. above the level of the client's chest
- B. at the level of the client's shoulders
- C. at the level of the chest
- D. below the level of the chest
Correct Answer: D
Rationale: A chest drainage system should be placed below the level of the client's chest to ensure proper drainage of fluid from the chest. Placing the system above the level of the chest or at the shoulders would not allow gravity to assist in the drainage process, potentially leading to complications such as fluid accumulation. Similarly, placing it at the level of the chest would not create the necessary gravity-dependent flow for effective drainage, which is crucial for the proper functioning of the chest drainage system.
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Which of these should not be included when calculating a client's fluid intake?
- A. ice chips
- B. Jell-Oâ„¢
- C. pudding
- D. IV fluid from an antibiotic piggyback
Correct Answer: C
Rationale: Pudding is a semi-solid and does not contribute significantly to fluid intake as it does not melt at room temperature. Therefore, it should not be included in fluid intake calculations. On the other hand, ice chips, Jell-Oâ„¢, and IV fluid from an antibiotic piggyback are all sources of fluid that can significantly contribute to a client's total fluid intake and should be considered when calculating it. Ice chips and Jell-Oâ„¢ provide hydration upon melting, while IV fluid directly adds to the fluid volume in the body.
The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?
- A. a 63-year-old female undergoing chemotherapy for breast cancer
- B. a 56-year-old female with dementia undergoing a swallow study
- C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
- D. a 45-year-old male recovering from a knee replacement under general anesthesia
Correct Answer: D
Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected due to the effects of the anesthesia on gut motility. For the other clients, hearing less than 5 bowel sounds per minute would indicate an abnormal finding. In the context of the given situation, the client recovering from knee replacement surgery aligns with the expected range of bowel sounds post-general anesthesia. Therefore, choice D is the correct answer. Choices A, B, and C present scenarios where hearing less than 5 bowel sounds per minute would be abnormal, indicating potential issues that need further evaluation.
Which of the following nursing diagnoses might be appropriate as Parkinson's disease progresses and complications develop?
- A. Impaired Physical Mobility
- B. Dysreflexia
- C. Hypothermia
- D. Impaired Dentition
Correct Answer: A
Rationale: The correct answer is 'Impaired Physical Mobility.' As Parkinson's disease progresses, clients may experience a shuffling gait and rigidity, leading to impaired physical mobility. This nursing diagnosis is relevant to address the functional limitations that may arise. 'Dysreflexia' is not typically associated with Parkinson's disease but rather with spinal cord injuries. 'Hypothermia' is a condition of abnormally low body temperature and is not a common complication of Parkinson's disease. 'Impaired Dentition' refers to dental issues and is not directly related to the progression of Parkinson's disease.
What is mammography used to detect?
- A. pain
- B. tumor
- C. edema
- D. epilepsy
Correct Answer: B
Rationale: Mammography is a diagnostic imaging technique specifically designed to detect tumors, cysts, or other abnormalities in breast tissue. It is not used to detect pain, edema, or epilepsy. Pain is a symptom, not a condition that mammography can detect. Edema refers to swelling and is not detectable through mammography. Epilepsy is a neurological disorder, not a condition detected by mammography.
An LPN is caring for a primarily bedridden client. Which finding should be of least concern?
- A. swollen feet
- B. brown discoloration above the ankles
- C. leg pain
- D. capillary refill time of 3 seconds on the big toe
Correct Answer: D
Rationale: The correct answer is the capillary refill time of 3 seconds on the big toe. A capillary refill time longer than three seconds may indicate inadequate blood flow. Swollen feet, brown discoloration above the ankles, and leg pain are all signs of venous insufficiency to the lower extremities. These findings can suggest circulation issues and require further assessment and intervention. Therefore, they should be of more concern compared to the capillary refill time of 3 seconds on the big toe, which is within the normal range of 2-3 seconds.