Nokea
Which assignment should not be delegated to the licensed practical nurse?
- A. Inserting a Foley catheter
- B. Discontinuing a nasogastric tube
- C. Obtaining a sputum specimen
- D. Starting a blood transfusion
Correct Answer: D
Rationale: Starting a blood transfusion requires RN-level assessment and monitoring due to the risk of transfusion reactions, which is outside the LPN’s scope in most settings. Foley insertion, NG tube discontinuation, and sputum collection are within LPN scope.
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The nurse is caring for a client with pneumonia who is allergic to penicillin. Which antibiotic is safest to administer to this client?
- A. Cefazolin (Ancef)
- B. Amoxicillin
- C. Erythrocin (Erythromycin)
- D. Ceftriaxone (Rocephin)
Correct Answer: C
Rationale: Erythromycin, a macrolide, is safe for penicillin-allergic patients. Cefazolin (A), Amoxicillin (B), and Ceftriaxone (D) are beta-lactams with cross-reactivity risks.
The nurse is caring for a client with a history of a pneumothorax who is being discharged. The nurse should teach the client to:
- A. Resume heavy lifting
- B. Avoid swimming
- C. Report chest pain immediately
- D. Sleep on the affected side
Correct Answer: C
Rationale: Chest pain post-pneumothorax may indicate recurrence or complications, requiring immediate reporting. Heavy lifting and swimming are restricted, and sleeping position is not critical.
A 22-year-old client presents with a diagnosis of antisocial personality disorder and a history of using drugs, writing numerous checks with insufficient funds, and stealing. He appears charming and intelligent, and the other clients are impressed and want to be liked by him. The greatest problem that may arise from this situation is that:
- A. He will manipulate the other clients for his own benefit
- B. He will cause the other clients to become psychotic
- C. He will become delusional and hallucinate as a result of the excess attention given to him by peers
- D. He may exhibit self-mutilative behavior
Correct Answer: A
Rationale: This answer is correct. Persons with antisocial personality disorder typically are very manipulative. This answer is incorrect. The client's behavior cannot cause another person to become psychotic. This answer is incorrect. Psychosis is not a symptom of antisocial personality. One of the criteria for diagnosis of this disorder is that no psychosis be present. In addition, the client would love the attention. This answer is incorrect. Self-mutilative behavior is characteristic of the borderline personality disorder.
A female client decides on hemodialysis. She has an internal vascular access device placed. To ensure patency of the device, the nurse must:
- A. Assess the site for leakage of blood or fluids
- B. Auscultate the site for a bruit
- C. Assess the site for bruising or hematoma
- D. Inspect the site for color, warmth, and sensation
Correct Answer: B
Rationale: This is an internal device. Assessment of the site should include assessing for swelling, pain, warmth, and discoloration. This measure does not assess patency. The presence of a bruit indicates good blood flow through the device. The nurse should inspect the site for bruising or hematoma; however, this measure does not assure patency of the device. The nurse should inspect the vascular access site frequently for signs of infection. However, this does not assure patency.
In planning daily care for a client with multiple sclerosis, the nurse would take into consideration that multiple sclerosis:
- A. Becomes progressively debilitating without remission
- B. Has unpredictable remissions and exacerbations
- C. Is rapidly fatal
- D. Responds quickly to antimicrobial therapy
Correct Answer: B
Rationale: Multiple sclerosis eventually becomes debilitating, but it is characterized by remission of symptoms. Remissions and exacerbations are unpredictable with multiple sclerosis. The client experiences progressive dysfunction after each exacerbation episode. Multiple sclerosis is usually slowly progressive. Multiple sclerosis is an autoimmune disease. Antimicrobial therapy has no effect on its course.