Nokea
When making an occupied bed, it is important for the nurse to:
- A. keep the bed in the low position.
- B. use a bath blanket or top sheet for warmth and privacy.
- C. constantly keep side rails raised on both sides.
- D. move back and forth from one side to the other when adjusting the linens.
Correct Answer: B
Rationale: Using a bath blanket or top sheet keeps the client warm and provides privacy. Keeping the bed in the low position and working above raised side rails might strain the nurse's back. Continually moving back and forth to tuck and arrange linen is time-consuming and disorganized.
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The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate need for teaching reinforcement?
- A. Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often.
- B. I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding.
- C. I can clean around the tube with water and mild soap.
- D. I should avoid using Vaseline around the nostril and tube.
Correct Answer: A
Rationale: Even when an NG tube is in place, the client still should brush his or her teeth twice daily. Good oral hygiene reduces the risk of introducing bacteria that may cause an infection.
The nurse is caring for the newly admitted male client who is unconscious. The UAP asks if the client should be shaved. What is the nurse's best response?
- A. I need to find out the client's preferences first.
- B. Shave him only after you have bathed him.
- C. Use the electric razor when you shave him.
- D. Avoid shaving him. I need a doctor's order.
Correct Answer: A
Rationale: A: Removal of facial hair varies based on personal and cultural preferences, which should be assessed first. B: Bathing order is irrelevant without preferences. C: Electric razors are safe but preferences are unknown. D: Shaving does not require a doctor's order.
The nurse is giving report to the NA on the care of four clients. The nurse should inform the NA to avoid taking a rectal temperature for which client?
- A. Adult who underwent ileostomy surgery because of a perforated bowel
- B. Adult who has a productive cough and is receiving oxygen by nasal cannula
- C. Adult who develops thrombocytopenia after receiving chemotherapy treatments
- D. Adult who has hypothermia after being outside in a below-zero temperature
Correct Answer: C
Rationale: C: Thrombocytopenia increases bleeding risk, making rectal temperatures unsafe. A: Ileostomy doesn't affect rectal area. B: Cough and oxygen don't contraindicate rectal temperatures. D: Rectal temperatures are used for hypothermia.
While repositioning the client, the LPN notices a shallow, open ulcer on the sacrum with partial-thickness skin loss. What is the classification stage of this ulcer?
- A. Stage I
- B. Stage IV
- C. Stage II
- D. Stage III
Correct Answer: C
Rationale: An ulcer is classified as stage II when the skin is not intact and there is partial-thickness skin loss. An ulcer with full-thickness skin loss would be stage III.
The NSAID that is comparable to morphine in efficacy is:
- A. Feldene.
- B. Stodal.
- C. Toradol.
- D. Elavil.
Correct Answer: C
Rationale: Toradol is the first injectable NSAID equal to morphine in efficacy.