Nokea
Which task should not be performed by the licensed practical nurse?
- A. Inserting a Foley catheter
- B. Discontinuing a nasogastric tube
- C. Obtaining a sputum specimen
- D. Initiating a blood transfusion
Correct Answer: D
Rationale: A licensed practical nurse should not initiate a blood transfusion. LPNs can assist with transfusions and verify ID numbers but should not be assigned to initiate the procedure. Inserting Foley catheters, discontinuing nasogastric tubes, and obtaining sputum specimens are within the scope of practice for LPNs. Therefore, options A, B, and C are tasks that LPNs can perform, making them incorrect choices.
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Using clichés in therapeutic communication leads the client to:
- A. viewing the nurse as less understanding.
- B. accepting themselves as human.
- C. self-disclosing.
- D. feeling discounted.
Correct Answer: D
Rationale: The use of clichés in therapeutic communication is commonly construed by the client as the nurse's lack of understanding, involvement, and caring, which can lead the client to feel demeaned and discounted. Choice A is incorrect because clichés do not make the client view the nurse as less understanding but rather as lacking depth in communication. Choice B is incorrect as clichés do not directly lead the client to accepting themselves as human. Choice C is incorrect because clichés usually hinder self-disclosure rather than encourage it.
Which intervention should the nurse take first to assist a woman who states that she feels incompetent as the mother of a teenage daughter?
- A. Recommend that she discipline her daughter more strictly and consistently.
- B. Make a list of things she can do to help improve her husband.
- C. Assist the mother to identify what she believes is preventing her success and what she can do to improve.
- D. Explore with the mother what the daughter can do to improve her behavior.
Correct Answer: C
Rationale: The priority intervention for a mother who feels incompetent in parenting a teenage daughter is to assist her in identifying the factors contributing to her feelings of inadequacy and help her develop better coping and mothering skills. This approach focuses on addressing the mother's emotional needs and empowering her to improve her situation. Option A is incorrect as it focuses on the daughter's discipline, which may not be the root cause of the mother's feelings. Option B is irrelevant as it focuses on improving her husband, not her parenting skills. Option D is incorrect as it shifts the focus solely to the daughter's behavior, neglecting the mother's emotional needs and self-improvement.
The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?
- A. Cyanocobalamin
- B. Protamine sulfate
- C. Streptokinase
- D. Sodium warfarin
Correct Answer: B
Rationale: The correct answer is Protamine sulfate. Protamine sulfate is the antidote for heparin, as it reverses its effects. Cyanocobalamin is a form of Vitamin B12 and is not used to reverse heparin effects. Streptokinase is a thrombolytic agent that is used to dissolve blood clots, not to reverse heparin effects. Sodium warfarin is an anticoagulant, but it is not the antidote for heparin. Therefore, answers A, C, and D are incorrect as they do not reverse the effects of heparin.
A woman seeks assistance because she recently remembered childhood sexual abuse. The nurse should include which of the following goals for this client?
- A. prosecuting the perpetrator
- B. managing symptoms of anxiety and fear
- C. determining if the memories are real
- D. collaborating with the client's story
Correct Answer: B
Rationale: The correct answer is 'managing symptoms of anxiety and fear.' When a client remembers childhood sexual abuse, the nurse's primary goal should be to help the client cope with the emotional distress and symptoms such as anxiety and fear. Prosecuting the perpetrator is not within the nurse's scope of practice and is a legal matter. Determining if the memories are real is not the nurse's role; the focus should be on providing support and care. Collaborating with the client's story is vague and does not address the immediate emotional needs of the client.
While assessing a client who is dying for signs of impending death, what should the nurse observe for?
- A. Elevated blood pressure
- B. Cheyne-Stokes respiration
- C. Elevated pulse rate
- D. Decreased temperature
Correct Answer: B
Rationale: When assessing a client for signs of impending death, the nurse should observe for Cheyne-Stokes respiration. This pattern involves rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea. It is often associated with cardiac failure and can be a significant indicator of impending death. Elevated blood pressure and pulse rate are not typical signs of impending death; in fact, they may indicate other conditions. A decreased temperature is also not a common sign of impending death, as temperature changes can vary among individuals and may not always correlate with the dying process.