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Which task should be delegated to the LPN/LVN?
- A. Gently cleanse the amputated digits with Betadine solution
- B. Place the amputated digits directly into ice slurry
- C. Wrap the amputated digits in sterile gauze moistened with saline
- D. Store the amputated digits in a solution of sterile normal saline
Correct Answer: C
Rationale: Wrapping the digits in sterile gauze moistened with saline is a simple task that can be performed by an LPN/LVN.
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What causes an audible wheeze in Mr. Ross’ right lung?
- A. Inflammation of pleural surfaces
- B. Obstruction of the bronchus
- C. Collection of exudate in the pleural cavity
- D. Dilatation of the alveoli
Correct Answer: B
Rationale: Bronchial obstruction leads to turbulent airflow, producing wheezing.
When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?
- A. Try to vigorously stimulate normal breathing.
- B. Ask the RN to assess the vital signs.
- C. Measure the pulse oximetry.
- D. Continue to monitor respirations.
Correct Answer: C
Rationale: Pulse oximetry provides critical data on oxygenation.
A 56-year-old patient comes to the walk-in clinic for scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history for colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis?
- A. Diarrhea/Constipation related to altered bowel patterns.
- B. Knowledge Deficit related to disease process and diagnostic procedure.
- C. Risk for Fluid Volume Deficit related to rectal bleeding and diarrhea.
- D. Anxiety related to unknown outcomes and perceived threats to body integrity.
Correct Answer: D
Rationale: The patient's anger and threat to leave indicate significant anxiety, which must be addressed before proceeding with education or further assessment.
Why should the nurse closely monitor older adults when they are receiving IV therapy?
- A. Because their defense mechanisms are less efficient.
- B. Because they are prone to fluid overload.
- C. Because they are prone to increased renal efficiency.
- D. Because they have inadequate intake of dietary fiber.
Correct Answer: B
Rationale: The correct answer is B because older adults are more susceptible to fluid overload due to decreased kidney function and other physiological changes.
To prevent airway obstruction in the postoperative patient who is unconscious or semiconscious, what will the nurse do?
- A. Encourage deep breathing
- B. Elevate the head of the bed
- C. Administer oxygen per mask
- D. Position the patient in a side-lying position
Correct Answer: D
Rationale: Side-lying position prevents tongue obstruction and facilitates drainage of secretions.