Nokea
While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
- A. Politely tells the client, 'Keep your hands off'
- B. Ignores the remarks and hopes he will not try it again
- C. Confronts the remarks but attempts not to reject the client
- D. Leaves the room in order to compose herself
Correct Answer: C
Rationale: By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship.
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Which assignment should not be delegated to the licensed practical nurse?
- A. Inserting a Foley catheter
- B. Discontinuing a nasogastric tube
- C. Obtaining a sputum specimen
- D. Starting a blood transfusion
Correct Answer: D
Rationale: Starting a blood transfusion requires RN-level assessment and monitoring due to the risk of transfusion reactions, which is outside the LPN’s scope in most settings. Foley insertion, NG tube discontinuation, and sputum collection are within LPN scope.
The client is prescribed warfarin (Coumadin). Which food should the nurse instruct the client to limit?
- A. Spinach
- B. Apples
- C. Chicken
- D. Rice
Correct Answer: A
Rationale: Spinach is high in vitamin K, which antagonizes warfarin’s anticoagulant effect, potentially reducing its efficacy. Apples, chicken, and rice have negligible vitamin K.
The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?
- A. Never use abdominal site for a rotation site.
- B. Pinch the skin up to form a subcutaneous pocket.
- C. Avoid applying pressure after injection.
- D. Change needles after injection.
Correct Answer: B
Rationale: Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. Massaging the site of injection facilitates absorption of the insulin. Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3-7 days.
A client was admitted to the hospital for a TURP. Within 48 hours of admission and 12 hours postoperatively, both the blood pressure and pulse increased. He became agitated, thought snakes were crawling on his arms and legs, and generally became unmanageable. He pulled out his IV and urinary catheter in attempt to rid himself of the snakes. He was sweating profusely. The admission nurse's notes indicated that the client admitted to 'having a few drinks now and then.' He is probably experiencing which of the following?
- A. Major psychotic depression
- B. Delirium tremens
- C. Generalized anxiety disorder
- D. Adjustment disorder with mixed features
Correct Answer: B
Rationale: Symptoms of psychotic depression must exist for at least 2 weeks, and the symptoms must represent a change from previous functioning. Delirium tremens occur approximately on the second or third day following cessation or reduction of alcohol intake. Symptoms would be all those described in the situation. Symptoms exhibited by this client are not exhibited in clients with anxiety disorders, who manifest excessive or unrealistic worry about life circumstances for at least 6 months. Symptoms for adjustment disorders with mixed emotional features (e.g., depression and anxiety) are different from those exhibited by the client in this situation.
The nurse is caring for a patient hospitalized with leukopenia. Which of the following assessments should be reported to the physician immediately?
- A. The blood pressure is 110/62.
- B. The apical pulse is 90.
- C. The temperature has increased from 98.6°F to 99.8°F.
- D. The respiratory rate is 24.
Correct Answer: C
Rationale: A temperature increase to 99.8°F in a patient with leukopenia (low white blood cell count) may indicate an infection which is a medical emergency due to the patient’s compromised immune system. The other vital signs are within normal limits and less urgent.