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Which task would be appropriate for the LPN to perform?
- A. Changing a colostomy bag.
- B. Hanging a new bag of TPN.
- C. Drawing a peak antibiotic blood level from a central line.
- D. Administering IV pain medication to a two-day post-op client.
Correct Answer: A
Rationale: The correct answer is changing a colostomy bag. This task falls within the LPN's scope of practice. LPNs are trained to provide basic nursing care, including assisting with activities of daily living and certain medical procedures like changing ostomy bags. Hanging a new bag of TPN and drawing a peak antibiotic blood level from a central line are tasks that require a higher level of training and are typically performed by RNs due to their complexity and potential risks. Administering IV pain medication to a two-day post-op client is usually the responsibility of an RN as it involves close monitoring, assessment of the client's condition, and the administration of potent medications that require a higher level of clinical judgment and expertise.
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One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:
- A. cor pulmonale.
- B. atelectasis.
- C. pulmonary embolism.
- D. cardiac tamponade.
Correct Answer: B
Rationale: The correct answer is atelectasis. The absence of breath sounds in the lower-right base is a key finding in atelectasis, which occurs when a portion of the lung collapses. The other symptoms such as dyspnea and increased respiratory rate could be present in various pulmonary conditions. Cor pulmonale is typically associated with chronic lung disease, pulmonary embolism presents with sudden onset dyspnea and chest pain, and cardiac tamponade manifests with Beck's triad of hypotension, distended neck veins, and muffled heart sounds.
Which client should the nurse see first?
- A. Recurring crushing chest pain
- B. Needing an IV for surgery in 5 minutes
- C. Needing PCA morphine for pain control post-hysterectomy
- D. Waiting to get back to bed after sitting in a chair for 30 minutes
Correct Answer: A
Rationale: The client presenting with recurring crushing chest pain should be seen first as this symptom could indicate a myocardial infarction (MI), which is a life-threatening condition requiring immediate attention. Assessing and managing potential cardiac issues take priority over other concerns like needing an IV for surgery, pain control post-hysterectomy, or assistance with mobility. While all clients require care, addressing the chest pain promptly is crucial to ensure the client's safety and well-being.
The nurse is caring for a client who is 28 weeks pregnant and complains of swollen hands and feet. Which symptom below would cause the greatest concern?
- A. Nasal congestion
- B. Hiccups
- C. Blood glucose of 150
- D. Muscle spasms
Correct Answer: D
Rationale: The correct answer is muscle spasms because they can be indicative of a severe condition like preeclampsia, which is a serious complication during pregnancy characterized by high blood pressure and signs of damage to another organ system, most often the liver and kidneys. Nasal congestion and hiccups are common discomforts during pregnancy and do not pose a severe risk to the client or fetus. A blood glucose level of 150, while slightly elevated, may not be alarming in a pregnant individual and can be managed through dietary modifications or medication adjustments. Muscle spasms, especially in the context of pregnancy, should be taken seriously and thoroughly assessed to rule out any underlying serious conditions.
The newborn nursery is filled to capacity. Which newborn should the nurse assess first?
- A. A three-hour-old just waking up after a period of sleep
- B. A two-day-old crying loudly
- C. A three-day-old two hours after circumcision
- D. A one-hour-old sucking his fist
Correct Answer: A
Rationale: The most critical time for assessment in a newborn is during the second period of reactivity, which occurs approximately 3-5 hours after delivery. During this phase, newborns are more likely to gag on mucus and aspirate, making it crucial for the nurse to assess their respiratory status first. Choice A indicates a newborn in this critical phase, requiring immediate assessment for potential airway compromise or respiratory distress. Choices B, C, and D do not present an immediate need for assessment related to airway compromise or respiratory distress.
During the admission assessment for a client undergoing breast augmentation, which information should the nurse prioritize reporting to the surgeon before surgery?
- A. The client is concerned about who will care for her two children while she recovers.
- B. The client has a history of postoperative dehiscence after a previous C-section.
- C. The client's statement that her last menstrual period was 8 weeks prior.
- D. The client's concerns over pain control postoperatively.
Correct Answer: C
Rationale: The most important information for the nurse to report to the surgeon before surgery is the client's statement that her last menstrual period was 8 weeks prior. This information is crucial as the client may be pregnant, and a pregnancy test will need to be completed before administering any anesthetic agents. Reporting this detail ensures patient safety and prevents potential risks associated with anesthesia. Choices A, B, and D are important aspects of care but do not take precedence over the need to rule out pregnancy before surgery.