Nokea
Which procedures are appropriate for the nurse to use when obtaining an adult client's blood for a laboratory test? Select all that apply.
- A. Avoid the arm on the affected side after a mastectomy
- B. Do not make further attempts to draw blood if unsuccessful on first 2 attempts
- C. If necessary to use an arm with IV infusing, draw proximal to infusion point
- D. Insert the needle bevel up at a 15-degree angle to the skin
- E. Obtain a finger capillary specimen from the middle of the finger pad
Correct Answer: A,B,C
Rationale: Avoiding the mastectomy side (A), limiting attempts to two (B), and drawing proximal to an IV (C) are correct. A 15-degree angle (D) is for IVs, not phlebotomy, and capillary samples avoid the finger pad center (E).
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The LPN is caring for a woman who delivered a healthy 7-lb baby boy 24 hours ago. Baseline vital signs were blood pressure (BP)=90/64, temperature (T)=97.6°F, pulse (P)=72, and respirations (R)=14. Which finding is of greatest concern?
- A. The woman has red vaginal drainage on her perineal pad.
- B. The woman complains of uterine cramping.
- C. The woman is drinking large amounts of water.
- D. The woman's vital signs are now BP=129/82, T=98.4°F, P=76, and R=16.
Correct Answer: D
Rationale: The significant rise in BP to 129/82 from 90/64 may indicate postpartum complications like preeclampsia, requiring immediate assessment. Red drainage, cramping, and increased water intake are normal postpartum findings.
The nurse has been teaching a woman who has iron deficiency anemia. Which menu, if selected, indicates that the woman understands her dietary instructions?
- A. Applesauce, green beans, bread, and butter
- B. Peanut butter and jelly sandwich, carrots, and milk
- C. Broccoli, spinach salad with tomatoes, and orange juice
- D. Macaroni and cheese, pickles, and hot chocolate
Correct Answer: C
Rationale: Broccoli, spinach, and orange juice (vitamin C enhances iron absorption) are iron-rich, ideal for anemia. Other menus lack sufficient iron sources.
A client who had bowel surgery is to be NPO for several days. The nurse anticipates that the client will have an order for:
- A. diet therapy.
- B. enteral nutrition.
- C. parenteral nutrition.
- D. nasogastric tube feedings.
Correct Answer: C
Rationale: Parenteral nutrition provides nutrients intravenously for clients NPO post-bowel surgery, bypassing the gastrointestinal tract.
The nurse is caring for a 10-year-old client with sickle cell disease who is experiencing an episode of acute pain. Which of the following diversional activities would be appropriate for the nurse to offer the client?
- A. putting together a puzzle in the activity room
- B. reading an age-appropriate book
- C. walking down the unit hallways
- D. playing with finger puppets
Correct Answer: B
Rationale: Reading a book (B) is a calm, stationary activity suitable for pain management. Puzzles (A) may require movement, walking (C) could worsen pain, and puppets (D) may be too childish for a 10-year-old.
The nurse is caring for a client who has acute pericarditis. Which of the following findings would be a priority to follow up?
- A. chest pain that is worse with deep inspiration
- B. muffled heart tones and jugular venous distension
- C. pericardial friction rub auscultated at the left sternal border
- D. temperature of 100.7 F (38.2 C) and a nonproductive cough
Correct Answer: B
Rationale: Muffled heart tones and jugular venous distension (B) suggest pericardial effusion or tamponade, a life-threatening complication requiring urgent follow-up. Chest pain (A) and friction rub (C) are expected, and mild fever (D) is less urgent.