Nokea
Which of these clients would be most appropriate to assign to a practical nurse (PN)?
- A. A trauma victim with quadriplegia and a client 1 day post-op radical neck dissection
- B. A client with newly diagnosed type 2 diabetes mellitus and a client with a history of AIDS admitted for pneumonia
- C. A client with hemiplegia is fed by a nasogastric tube and client with a left leg amputation in rehabilitation
- D. A client with a history of schizophrenia in alcohol withdrawal and a client with chronic renal failure
Correct Answer: C
Rationale: This client requires supportive care and interventions within the scope of practice of a PN. This client is stable with little risk of complications or instability.
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Laboratory Reference Ranges
Creatinine
Male: 0.6–1.3 mg/dL
(53–114.9 μmol/L)
Female: 0.5–1.2 mg/dL
(44.2–106.1 μmol/L)
The nurse is planning to assess 4 assigned clients. Which client situation is of greatest concern and warrants immediate assessment?
- A. Client scheduled for hemodialysis in an hour who has a serum creatinine level of 9.2 mg/dL (813 µmol/L) and refuses to take prescribed medications
- B. Client taking diphenhydramine for urticaria who reports difficulty urinating and increasing lower abdominal pain
- C. Client with an infected venous leg ulcer prescribed IV vancomycin who has a dressing saturated with yellow, foul-smelling drainage
- D. Client with an inguinal hernia who rates abdominal pain as 10 on a 0-10 scale and reports bloating, nausea, and vomiting
Correct Answer: D
Rationale: Severe pain (10/10) with bloating, nausea, and vomiting in an inguinal hernia suggests strangulation, a surgical emergency. High creatinine, urinary retention, and infected ulcers are urgent but less immediately life-threatening.
The nurse is administering a tap water enema when the client begins to complain of abdominal cramping. The nurse should:
- A. Stop the administration of the enema.
- B. Lower the height of the enema container.
- C. Clamp the enema tubing and withdraw it slowly.
- D. Advance the tubing 1-2 inches.
Correct Answer: B
Rationale: Lowering the enema container slows the flow, reducing cramping. Stopping or withdrawing the tubing is premature, and advancing may worsen discomfort.
An adult client is to have a portable chest x-ray in his room. The client's wife and pregnant daughter are visiting. Which action is essential for the nurse?
- A. Ask the pregnant daughter to leave the room and have the wife assist in holding the client.
- B. Have the client wear a lead apron over his chest and abdomen.
- C. Close the door to the room securely during the x-ray.
- D. Ask the wife and daughter to leave the room.
Correct Answer: D
Rationale: Removing visitors, especially a pregnant woman, minimizes radiation exposure, the essential safety action during a chest x-ray.
The nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches for angina. Which of the following statements by the client would require follow-up?
- A. I can apply a new patch to my arm or chest each day
- B. I should avoid placing the patch over areas with a lot of hair
- C. I should remove the patch at night to prevent tolerance
- D. I will apply the patch only when I experience chest pain
Correct Answer: D
Rationale: Nitroglycerin patches are for angina prevention, applied daily, not as-needed. Rotating sites, avoiding hair, and removing at night (patch-free interval) are correct.
A 3 year-old child is treated in the emergency department after ingestion of 1 ounce of a liquid narcotic. What action should the nurse perform first?
- A. Provide the ordered humidified oxygen via mask
- B. Suction the mouth and the nose
- C. Check the mouth and radial pulse
- D. Start the ordered intravenous fluids
Correct Answer: C
Rationale: Check the mouth and radial pulse. Assessing airway, breathing, and circulation is the first step in treating toxic ingestion to stabilize the client.