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When evaluating a client's use of a cane, which action should the nurse identify as an indication of correct use?
- A. The client's stronger side holds the cane
- B. The top of the cane is parallel to the client's waist
- C. The client holds the cane on the stronger side of their body
- D. The client moves the cane 46 cm (18 in) forward
Correct Answer: C
Rationale: The correct way to use a cane is to hold it on the stronger side of the body. This helps to provide support and maintain alignment. Option A is incorrect because the cane should be held on the stronger side, not the weaker side. Option B is incorrect as the top of the cane should be at the level of the greater trochanter, not the waist. Option D is incorrect because the client should move the weaker limb forward with the cane for stability.
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A client is scheduled for a total laryngectomy. Which of the following interventions is the priority for the nurse?
- A. Schedule a support session for the client.
- B. Explain the techniques of esophageal speech.
- C. Review the use of artificial larynx with the client.
- D. Determine the client's reading ability.
Correct Answer: B
Rationale: The priority intervention for a client scheduled for a total laryngectomy is to explain the techniques of esophageal speech. This is crucial for the client's post-surgery communication. Option A, scheduling a support session, is important but not the priority as ensuring the client can communicate effectively comes first. Option C, reviewing the use of artificial larynx, is relevant but not the priority compared to teaching esophageal speech. Option D, determining the client's reading ability, is not as critical as ensuring the client learns a primary method of communication following the laryngectomy.
A client who is receiving chemotherapy for cancer treatment is experiencing nausea and vomiting. What is the best intervention for the LPN/LVN to implement?
- A. Offer the client small, frequent meals.
- B. Provide antiemetic medication as prescribed.
- C. Encourage the client to drink clear liquids.
- D. Assist the client with oral care.
Correct Answer: B
Rationale: The best intervention for a client experiencing chemotherapy-induced nausea and vomiting is to provide antiemetic medication as prescribed. This medication helps in managing and reducing nausea and vomiting, providing relief to the client. Offering small, frequent meals (Choice A) may not address the underlying cause of the symptoms. Encouraging clear liquid intake (Choice C) may not be effective in controlling nausea and vomiting associated with chemotherapy. Assisting with oral care (Choice D) is important for overall comfort but may not directly address the symptoms of nausea and vomiting.
A client is evaluated by a nurse regarding the use of a sequential compression device. Which of the following client statements indicates understanding of the device's purpose?
- A. "This device will keep me from developing skin sores."
- B. "This device will keep the blood circulating in my leg."
- C. "This device will prevent my leg muscles from weakening."
- D. "This device will maintain the health of my joints."
Correct Answer: B
Rationale: The correct answer is B because sequential compression devices are utilized to enhance circulation and prevent clot formation in the legs. Option A is incorrect because these devices are not primarily meant to prevent skin sores. Option C is incorrect because the devices do not directly address muscle weakness. Option D is incorrect as the main purpose of sequential compression devices is not related to joint health.
A client with diabetes mellitus is experiencing polyuria, polydipsia, and polyphagia. What is the most important action for the LPN/LVN to take?
- A. Encourage the client to increase fluid intake.
- B. Monitor the client's blood glucose level.
- C. Administer insulin as prescribed.
- D. Assess the client's urine output.
Correct Answer: B
Rationale: The correct answer is to monitor the client's blood glucose level. When a client with diabetes mellitus presents with symptoms of polyuria, polydipsia, and polyphagia, it indicates hyperglycemia. Monitoring blood glucose levels is crucial to assess and manage the client's condition effectively. Option A, encouraging the client to increase fluid intake, may exacerbate polyuria. Option C, administering insulin, should be done based on the healthcare provider's prescription after assessing the blood glucose level. Option D, assessing the client's urine output, is important but not the most immediate action needed in this scenario; monitoring blood glucose levels takes precedence.
A healthcare provider is monitoring a client for adverse effects following the administration of an opioid. Which of the following effects should the provider identify as an adverse effect of opioids?
- A. Urinary incontinence
- B. Diarrhea
- C. Bradypnea
- D. Orthostatic hypotension
Correct Answer: D
Rationale: The correct answer is D: Orthostatic hypotension. Opioids can cause orthostatic hypotension, leading to a sudden drop in blood pressure when changing positions. This effect is due to the vasodilatory properties of opioids, which can result in decreased blood flow to the brain upon standing up. Choices A, B, and C are incorrect. Urinary incontinence and diarrhea are not typical adverse effects of opioids. Bradypnea, or slow breathing, is a potential side effect of opioid overdose or respiratory depression, but it is not a common adverse effect following normal opioid administration.