Nokea
Which task is most appropriate to delegate to an LPN /LVN?
- A. Talk to a community group about water safety issues
- B. Stabilize the cervical spine for an unconscious drowning victim
- C. Remove wet clothing and cover the victim with a warm blanket
- D. Monitor an asymptomatic near-drowning victim
Correct Answer: C
Rationale: Removing wet clothing and covering the victim with a warm blanket is a straightforward task suitable for an LPN/LVN.
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For the nursing diagnoses and written patient outcomes listed below, use the Nursing Interventions Classification (NIC) to identify a specific nursing intervention to help the patient reach the outcome.
- A. Risk for impaired skin integrity related to immobility
- B. Constipation related to inadequate fluid and fiber intake
- C. None
- D. All
Correct Answer: A
Rationale: For preventing pressure ulcers, interventions like turning and positioning are critical. For constipation, increasing fluid and fiber intake is key.
While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?
- A. Obtain a cardiology consult.
- B. Suction the client less frequently.
- C. Administer an antidysrhythmic medication.
- D. Perform pre-oxygenation prior to suctioning.
Correct Answer: D
Rationale: The correct answer is D: Perform pre-oxygenation prior to suctioning. In this scenario, the increase in heart rate and irregularity could be due to hypoxia resulting from suctioning. Pre-oxygenation helps to ensure adequate oxygenation before the procedure, preventing hypoxia-induced dysrhythmias. By providing oxygen before suctioning, the nurse can minimize the risk of further complications.
Choice A (Obtain a cardiology consult) is incorrect because immediate action is required to address the potential hypoxia, which can be managed by pre-oxygenation.
Choice B (Suction the client less frequently) is incorrect as it does not address the immediate concern of potential hypoxia leading to dysrhythmias.
Choice C (Administer an antidysrhythmic medication) is incorrect as it is not the initial intervention needed in this situation; addressing the underlying cause of potential hypoxia is essential before considering antidysrhythmic medications.
Which of the following would be appropriate to delegate to the nursing assistant?
- A. Assist the child to remove outer clothing
- B. Advise the parent to use acetaminophen instead of aspirin
- C. Explain the need for cool fluids
- D. Prepare and administer a tepid bath
Correct Answer: A
Rationale: Removing outer clothing is a simple task that does not require clinical judgment.
18. Melatonin’s use is based on scientific evidence. The patient with which problem would benefit from melatonin?
- A. Sleep problems
- B. Mild depression
- C. High cholesterol
- D. Benign prostatic hyperplasia
Correct Answer: A
Rationale: Melatonin is scientifically supported for addressing sleep problems (option A), such as insomnia or jet lag.
Medications are given to older adults for many different conditions. A good rule to follow for medication use in older adults is to:
- A. Use once daily dosing
- B. Take all medications at the same time
- C. Request brand name medications
- D. Use the lowest possible effective dose
Correct Answer: D
Rationale: Older adults are more sensitive to medications due to decreased kidney and liver function. Using the lowest effective dose minimizes side effects and drug interactions.