Nokea
When admitting a client to an acute care facility, an identification bracelet is sent up with the admission form. In the event these do not match, the nurse's best action is to
- A. Change whichever item is incorrect to the correct information
- B. Use the bracelet and admission form until a replacement is supplied
- C. Notify the admissions office and wait to apply the bracelet
- D. Make a corrected identification bracelet for the client
Correct Answer: C
Rationale: The nurse should notify the admissions office and wait to apply the bracelet. By doing so, the nurse ensures patient safety and accuracy in identification. Changing the incorrect item (Choice A) could lead to errors and confusion in the patient's identification. Using the mismatched items until a replacement is supplied (Choice B) compromises patient safety and could result in errors during care delivery. Making a corrected identification bracelet without verifying the correct information (Choice D) could introduce further inaccuracies and risks in patient identification.
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A client is admitted with a diagnosis of septicemia. Which assessment finding should the LPN/LVN report to the healthcare provider immediately?
- A. Increased urine output
- B. Decreased blood pressure
- C. Increased heart rate
- D. Increased respiratory rate
Correct Answer: B
Rationale: In a client with septicemia, decreased blood pressure is a critical finding that suggests potential septic shock, a life-threatening condition. Septic shock requires immediate medical intervention to prevent further deterioration and organ dysfunction. Increased urine output (Choice A) may indicate adequate fluid resuscitation, which is a positive response. Increased heart rate (Choice C) and increased respiratory rate (Choice D) are common physiological responses to sepsis and do not necessarily indicate immediate life-threatening complications like decreased blood pressure does in septic shock.
A client returns from surgery with two Penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site?
- A. Montgomery straps
- B. Sterile gauze
- C. Adhesive tape
- D. Elastic bandages
Correct Answer: A
Rationale: Montgomery straps are the correct choice in this scenario. They are specifically designed to secure dressings around drain sites, like Penrose drains, and are ideal for frequent dressing changes. Sterile gauze (Choice B) is commonly used for wound dressings but may not provide the best securement for drains. Adhesive tape (Choice C) can cause skin irritation and may not be suitable for securing drains. Elastic bandages (Choice D) are typically used for compression or support but are not appropriate for securing dressings around drain sites.
Which action is most important for maintaining sterility when donning sterile gloves?
- A. Maintain thumbs at a ninety-degree angle.
- B. Hold hands with fingers pointing downward while gloving.
- C. Keep gloved hands above the elbows.
- D. Put the glove on the dominant hand first.
Correct Answer: C
Rationale: The most crucial action for maintaining sterility when donning sterile gloves is to keep gloved hands above the elbows. This practice is essential to prevent potential contamination and maintain a sterile field. Choices A, maintaining thumbs at a ninety-degree angle, and B, holding hands with fingers pointing downward while gloving, are not as critical as keeping hands above the elbows for maintaining sterility. Choice D, putting the glove on the dominant hand first, is not as important as ensuring that gloved hands are kept above the elbows to maintain sterility.
A client with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client is short of breath and has a pulse oximetry reading of 88%. What action should the LPN take first?
- A. Increase the oxygen flow rate to 4 liters per minute.
- B. Reposition the client to a high Fowler's position.
- C. Notify the healthcare provider of the client's condition.
- D. Encourage the client to use pursed-lip breathing.
Correct Answer: B
Rationale: Repositioning the client to a high Fowler's position should be the first action taken by the LPN. This position helps improve oxygenation by maximizing lung expansion, making it easier for the client to breathe. Increasing the oxygen flow rate without addressing positioning may not fully optimize oxygen delivery. Notifying the healthcare provider should come after immediate interventions. Encouraging pursed-lip breathing is beneficial but should follow the initial positioning to further assist the client in managing their breathing difficulty.
A client is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?
- A. Drink a cup of hot cocoa before bedtime
- B. Exercise 1 hour before going to bed
- C. Use progressive relaxation techniques at bedtime
- D. Reflect on the day's activities before going to bed
Correct Answer: C
Rationale: The correct answer is to recommend the client to use progressive relaxation techniques at bedtime. Progressive relaxation techniques help reduce stress and muscle tension, which can promote better sleep. Choice A, drinking a cup of hot cocoa before bedtime, contains caffeine which can interfere with falling asleep. Choice B, exercising 1 hour before going to bed, can stimulate the body and mind, making it harder to fall asleep. Choice D, reflecting on the day's activities before going to bed, may lead to increased mental activity and prevent relaxation, making it difficult to fall asleep.