Nokea
While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?
- A. Unplug the bed's power source.
- B. Remove the client from the bed immediately.
- C. Notify the biomedical department at once.
- D. Turn off the oxygen.
Correct Answer: A
Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.
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A client with dysphagia is ready to eat lunch. Which of these foods on the tray would be best to start with when assisting the client?
- A. diced fruit
- B. apple juice with a liquid thickener
- C. Jell-O™
- D. toast
Correct Answer: B
Rationale: The correct choice is apple juice with a liquid thickener. A client with dysphagia is at risk for aspiration, so it is crucial to start with liquids and assess the client's ability to swallow before introducing solid foods. Using a liquid thickener with apple juice allows the healthcare provider to evaluate swallowing function. Jell-O™, although it melts into a clear liquid, should be avoided initially as it may not provide a clear assessment of swallowing ability. Diced fruit and toast are solid foods that should be introduced only after the client's swallowing ability with liquids has been assessed.
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.
An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?
- A. Inability to turn, cough, and breathe deeply
- B. Inability to communicate pain
- C. Inability to ambulate freely
- D. Inability to use a bedside commode
Correct Answer: B
Rationale: The correct answer is B: Inability to communicate pain. In this scenario, the client's aphasia prevents them from verbally expressing their pain, which can lead to inadequate pain management if the healthcare team is not vigilant. The nurse must use alternative methods to assess and address the client's pain. Choices A, C, and D, although important considerations in postoperative care, do not directly relate to the client's ability to communicate pain, which is crucial for effective pain management in this case.
Which is the proper hand position for performing chest percussion?
- A. Use the side of the hands
- B. Flatten the hands
- C. Spread the fingers of both hands
- D. Cup the hands
Correct Answer: D
Rationale: The proper hand position for performing chest percussion is to cup the hands. Cupping the hands helps produce a vibration that aids in loosening respiratory secretions effectively. This technique is essential for therapeutic chest physiotherapy. Using the side of the hands, flattening the hands, or spreading the fingers of both hands do not generate the necessary vibration required for chest percussion. These hand positions are not considered proper techniques in this context and may not provide the desired therapeutic effect.
After administering medication through an NG tube, the client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 5 minutes if your NG residual is below 50 mLs.
- C. You can lie down in about 30 minutes.
- D. Yes, feel free to lie down.
Correct Answer: C
Rationale: The correct answer is to inform the client that they can lie down in about 30 minutes. After administering medication through an NG tube, it is recommended that the client remains upright for about 30 minutes to ensure proper absorption of the medications. Option A is incorrect as waiting for 1 hour is unnecessary. Option B is incorrect as the specified timeframe and condition given are not standard practice for lying down after NG tube medication administration. Option D is incorrect as it lacks guidance on the appropriate waiting time and does not emphasize the importance of waiting before lying down for optimal medication absorption.