Nokea
Which adaptations for performing the examination would be appropriate for the patient (select all that apply)?
- A. Make sure that a family member is with him.
- B. Handle the skin with care because of potential fragility.
- C. Keep the patient warm and comfortable during the assessment.
- D. Allow the patient to watch TV to distract him from any painful assessments.
Correct Answer: C
Rationale: The correct answers are 'Handle the skin with care because of potential fragility,' 'Keep the patient warm and comfortable during the assessment,' and 'Place the patient in a position of comfort and avoid unnecessary changes in position.' These adaptations address age-related vulnerabilities and promote patient cooperation.
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Which task is most appropriate for an LPN/LVN?
- A. Assess immediate emotional state and physical injuries
- B. Collect hair samples, saliva swabs, and scrapings beneath fingernails
- C. Provide emotional support and supportive communication
- D. Ensure that the 'chain of custody' is maintained
Correct Answer: C
Rationale: Providing emotional support is within the scope of an LPN/LVN and does not involve complex legal procedures.
A nurse in the PACU is assessing a client who has an endotracheal tube (ET) in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?
- A. Blockage of the ET tube by the client's tongue
- B. Passage of the ET tube into the esophagus
- C. Movement of the ET tube into the right main bronchus
- D. Infection of the vocal cords
Correct Answer: C
Rationale: The correct answer is C: Movement of the ET tube into the right main bronchus. When the nurse observes absence of left-sided chest wall expansion, it indicates that the ET tube may have moved into the right main bronchus. This can lead to inadequate ventilation of the left lung, causing unilateral chest wall expansion. The other choices are incorrect because: A) Blockage by the tongue would not result in unilateral chest wall expansion. B) Passage into the esophagus would lead to improper ventilation but not specifically affect one side of the chest. D) Infection of the vocal cords would not directly cause unilateral chest wall expansion.
A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Oxygen saturation of 95%
- B. No fluctuations in the water seal chamber
- C. No reports of pleuritic chest pain
- D. Occasional bubbling in the water-seal chamber
Correct Answer: B
Rationale: The correct answer is B: No fluctuations in the water seal chamber. This finding indicates that the lung has re-expanded because it means there is no air leaking from the lung into the pleural space, causing fluctuations in the water seal chamber. Option A, oxygen saturation of 95%, is not directly related to lung re-expansion. Option C, no reports of pleuritic chest pain, is a subjective symptom and does not provide a direct indication of lung re-expansion. Option D, occasional bubbling in the water-seal chamber, indicates air is escaping from the lung into the pleural space, suggesting incomplete lung re-expansion.
What is the nurse’s evaluation of Mr. Singer not testing for proper placement of his nasogastric tube?
- A. Mr. Singer must be stopped before the instillation of the feeding
- B. There is no possibility that the tube will get into Mr. Singer’s trachea
- C. If Mr. Singer shows no breathing difficulties, he can proceed with his feeding
- D. The greatest danger for Mr. Singer is the aspiration of the feeding into his lung
Correct Answer: D
Rationale: Aspiration poses a serious risk if the tube is misplaced.
The nurse is assessing a client with delayed wound healing. Which of the following risk factors is most important in this situation?
- A. Glucose level of 120 mg/dl.
- B. History of myocardial infarction.
- C. Long term steroid usage.
- D. Diet high in carbohydrates.
Correct Answer: C
Rationale: Steroids impair wound healing by affecting collagen formation and immune response.