Nokea
While observing a client using crutches for a leg injury, which action would indicate a need for more education by the LPN?
- A. The client places the top padding 1-2 inches below the axilla with a firm grip on the handles.
- B. The client rests the axilla on the top padding and loosely grips the handles with hands.
- C. The client has a slight bend in the elbow when using the handles.
- D. When going down the stairs, the client leads with the injured leg.
Correct Answer: B
Rationale: The correct answer is B. Resting the axilla on the top padding can cause nerve damage; instead, the client should place the top padding 1-2 inches below the axilla with a firm grip on the handles for proper support and stability while using crutches. Having a slight bend in the elbow when using the handles (choice C) is a correct technique to ensure proper weight distribution. Leading with the uninjured leg when going down the stairs (choice D) is the correct way to maintain balance and prevent further injury to the injured leg. Therefore, choice B indicates a need for more education to prevent potential nerve damage and ensure safe crutch use.
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What is the appropriate ratio of cardiac compressions to ventilations in an adult client for one-person CPR?
- A. 5:01
- B. 1:05
- C. 15:02
- D. 2:15
Correct Answer: C
Rationale: The correct answer is 15:2. For one-person CPR on an adult, the ratio of compressions to ventilations is 15:2. This ratio ensures adequate oxygenation while maintaining effective circulation. Choice A (5:1) and Choice B (1:5) are incorrect ratios and do not align with the recommended guidelines for adult CPR. Choice D (2:15) is also incorrect as it reverses the order of compressions and ventilations.
When placing a Foley catheter in a female client, what is the correct order of steps?
- A. E, A, F, B, C, G, D
- B. A, E, B, F, G, D, C
- C. A, E, F, B, C, G, D
- D. E, A, F, B, C, G, D
Correct Answer: D
Rationale: The correct order for placing a Foley catheter in a female client is as follows: E. Place the client in a supine position with flexed knees, A. Prepare the sterile field, F. Place lubricant on the catheter, B. Separate labia with the non-dominant hand, C. Clean the urinary meatus using cleansing solutions and forceps, G. Place the catheter in the meatus with the dominant (sterile) hand, and D. Inflate the catheter balloon. This sequence ensures proper hygiene, patient comfort, and reduces the risk of infection. Incorrect sequences could compromise sterility, cause discomfort, and increase the risk of infection. Therefore, the correct answer is E, A, F, B, C, G, D.
The nurse is teaching a client about erythema infectiosum. Which of the following factors is not correct?
- A. There is no rash.
- B. The disorder is uncommon in adults.
- C. There is no fever.
- D. There is sometimes a 'slapped face' appearance.
Correct Answer: B
Rationale: The correct answer is that the disorder is uncommon in adults. Erythema infectiosum, also known as Fifth's disease, commonly affects children and is characterized by a 'slapped face' appearance. It is associated with a rash and sometimes a low-grade fever. Therefore, the statement 'The disorder is uncommon in adults' is not correct, making it the correct answer. The other statements about the presence of a rash, 'slapped face' appearance, and the possibility of a fever are accurate in the context of erythema infectiosum.
How should the LPN document pain for a non-verbal client using the FLACC pain scale with these findings?
- A. 1
- B. 4
- C. 3
- D. 2
Correct Answer: B
Rationale: The correct answer is B: '4'. The FLACC pain scale assesses pain in non-verbal patients based on five categories: Face, Legs, Activity, Cry, and Consolability. In this case, the client exhibits occasional grimacing (1 point), relaxed legs (0 points), squirming (1 point), moans and whimpers (1 point), and is distractible (1 point). Adding these points together results in a total pain score of 4. Therefore, the LPN should document a pain score of 4 for this non-verbal client. Choices A, C, and D are incorrect as they do not accurately reflect the total pain score based on the given findings.
A client expresses anxiety about having magnetic resonance imaging performed. Which of the following is an appropriate response by the nurse?
- A. "You can receive a sedative to help you relax during the test."?
- B. "There is absolutely nothing to worry about."?
- C. "There is no discomfort with this test, so don't be anxious."?
- D. "The test won't last long, so you can handle it."?
Correct Answer: A
Rationale: The correct response acknowledges the client's anxiety and offers a practical solution to alleviate it, showing empathy and addressing the client's concerns. Offering a sedative to help relax during the test is a proactive approach to managing the client's anxiety. Choices B and C dismiss the client's feelings by invalidating their anxiety, which can further escalate their distress. Choice D downplays the client's feelings by implying they should not be worried, which does not effectively address the client's emotional state.