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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The client is being assessed for possible pernicious anemia. Which finding would support this diagnosis?
- A. A weight loss of 10 pounds in 2 weeks
- B. Complaints of numbness and tingling in the extremities
- C. A red, beefy tongue
- D. A hemoglobin level of 12.0 g/dL
Correct Answer: C
Rationale: The correct answer is a red, beefy tongue, which is characteristic of pernicious anemia due to the atrophy of the papillae on the tongue. This finding is known as glossitis. A red, beefy tongue is a classic sign of pernicious anemia. Choice A, weight loss of 10 pounds in 2 weeks, is non-specific and not a typical finding in pernicious anemia. Choice B, complaints of numbness and tingling in the extremities, are more indicative of peripheral neuropathy, a common symptom of vitamin B12 deficiency, which can be seen in pernicious anemia. Choice D, a hemoglobin level of 12.0 g/dL, falls within the normal range and does not specifically point towards pernicious anemia, which is characterized by low hemoglobin levels due to impaired absorption of vitamin B12.
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.
The nurse is assisting the RN with discharge instructions for a client with an implantable defibrillator. What discharge instruction is essential?
- A. "You can eat food prepared in a microwave."?
- B. "You should avoid moving the shoulder on the side of the defibrillator site for 6 weeks."?
- C. "You should use your cellphone on your right side."?
- D. "You will be able to fly on a commercial airliner with the defibrillator in place."?
Correct Answer: C
Rationale: The essential discharge instruction for a client with an implantable defibrillator is to use any battery-operated machinery on the opposite side, including cellphones. This is to prevent interference with the device. Additionally, the client should monitor their pulse rate and report any dizziness or fainting, which could indicate issues with the defibrillator. Choices A, B, and D are incorrect because clients with implantable defibrillators can eat food prepared in the microwave, move their shoulder on the affected side after the initial healing period, and are allowed to fly on commercial airliners with the defibrillator in place.
In a brief treatment program, what is a realistic short-term goal for a client who was raped?
- A. Identify all psychosocial problems
- B. Eliminate the client's enticing behaviors
- C. Resolve feelings of trauma and fear
- D. Verbalize feelings about the event
Correct Answer: D
Rationale: A realistic short-term goal for a client who was raped and is receiving a brief treatment program is for the client to verbalize feelings about the event. This goal focuses on helping the client express their emotions, which can be a crucial step in the healing process. Options A and C are incorrect because a brief treatment program is not typically aimed at identifying or resolving all psychosocial problems or deep-rooted trauma and fear. Option B is also incorrect as the goal is to support the client in processing their feelings rather than focusing on behaviors.
The nurse is caring for a client with laryngeal cancer. Which finding ascertained in the health history would not be common for this diagnosis?
- A. Foul breath
- B. Dysphagia
- C. Diarrhea
- D. Chronic hiccups
Correct Answer: C
Rationale: Diarrhea is not a common finding in clients with laryngeal cancer. Foul breath (A), dysphagia (B), and chronic hiccups (D) are expected findings associated with laryngeal cancer. Foul breath can result from tissue breakdown in the mouth and throat. Dysphagia, or difficulty swallowing, can occur due to the tumor's location affecting the swallowing mechanism. Chronic hiccups can be a symptom of irritation to the phrenic nerves from the cancer.