Nokea
The nurse is assigned a team with another registered nurse and an LPN.
Which of the following patients should the nurse assign to the LPN?
- A. A 67-year-old man who is NPO and scheduled for a transurethral resection of the prostate (TURP) in 3 hours.
- B. A 53-year-old woman with an IV of 0.9% NaCl at 100 cc/h who had a lumbar laminectomy two days ago.
- C. A 40-year-old woman with a Hemovac drain and a large surgical dressing from a mastectomy 2 days ago who is showing signs of depression.
- D. A 27-year-old woman scheduled for discharge later today after receiving chemotherapy through a portacath for treatment of leukemia.
Correct Answer: B
Rationale: Strategy: The LPN/LVN is assigned stable patients with expected outcomes. (1) needs preoperative teaching and assessment (2) correct-basic care needs can be met by the LPN/LVN, don't make patient assignments based on equipment (3) needs therapeutic intervention, teaching, and assessment (4) needs assessment and teaching
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The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
- A. Impaired gas exchange related to acute infection and sputum production
- B. Ineffective airway clearance related to sputum production and ineffective cough
- C. Ineffective breathing pattern related to acute infection
- D. Anxiety related to hospitalization and role conflict
Correct Answer: B
Rationale: Ineffective airway clearance is defined as the inability to cough effectively, directly supported by the assessment data of crackles and ineffective cough.
An adult is being worked up for a possible duodenal ulcer. The nurse knows that which data, if present, would be most consistent with a duodenal ulcer?
- A. Two hours after his last meal, the client says, 'I need to feed my ulcer.'
- B. The client complains of epigastric pain a half hour after eating.
- C. The client has clay-colored stools.
- D. The client complains of pain beneath the right shoulder blade after eating.
Correct Answer: A
Rationale: Duodenal ulcers typically cause pain 2-3 hours after eating, relieved by food ('feeding the ulcer'), unlike pain immediately after eating (gastric ulcer), clay stools (biliary issues), or shoulder pain (gallbladder).
The nurse is assessing a client immediately after an exploratory laparotomy. Which of the following nursing observations would relate to the complication of inTest inal obstruction?
- A. Protruding soft abdomen with frequent diarrhea.
- B. Distended abdomen with ascites.
- C. Minimal bowel sounds in all four quadrants.
- D. Distended abdomen with complaints of pain.
Correct Answer: D
Rationale: if an obstruction is present, the abdomen will become distended and painful
The nurse is caring for a client with a history of hypertension who is receiving hydralazine (Apresoline) 25 mg PO tid. Which of the following findings should the nurse report immediately?
- A. Blood pressure of 130/80 mmHg
- B. Heart rate of 100 bpm
- C. Chest pain and shortness of breath
- D. Mild headache
Correct Answer: C
Rationale: Chest pain and shortness of breath suggest angina or lupus-like syndrome, serious hydralazine side effects. Options A, B, and D are less urgent: BP is normal, tachycardia is mild, and headache is common.
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Syndeham's chorea?
- A. Irregular movements of the arms and legs and facial grimacing
- B. Painless swellings over the surface of the joints
- C. Faint areas of red demarcation over the back
- D. Swelling and inflammation of the joints
Correct Answer: A
Rationale: Syndeham's chorea is characterized by irregular, involuntary movements and facial grimacing, so A is correct. Answers B, C, and D describe other rheumatic fever symptoms but not chorea.