Nokea
You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to an LPN/LVN?
- A. Complete admission assessment.
- B. Set up oxygen and suction equipment.
- C. Place a padded tongue blade at the bedside.
- D. Pad the side rails before the patient arrives.
Correct Answer: B
Rationale: The correct answer is to delegate the task of setting up oxygen and suction equipment to the LPN/LVN. This task falls within their scope of practice and can be safely performed by them. Completing the admission assessment (Choice A) typically requires a higher level of assessment and critical thinking, making it more appropriate for a registered nurse. Placing a padded tongue blade at the bedside (Choice C) involves potential airway management, which is a more complex task and should be done by a higher-level provider. Padding the side rails before the patient arrives (Choice D) is a task related to patient safety and should be done by the healthcare team as a whole, not solely delegated to an LPN/LVN.
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When preparing a patient on complete bed rest to eat, at what degree angle or more should you put the head of the bed up?
- A. 10
- B. 15
- C. 20
- D. 30
Correct Answer: D
Rationale: The correct answer is D: 30. When a patient is on complete bed rest, it is essential to elevate the head of the bed at a 30-degree angle or more before meals. This position helps prevent choking and aspiration of food during eating by promoting proper swallowing and digestion. Choices A, B, and C are incorrect because they do not provide the optimal elevation needed to support safe and effective feeding for a patient on complete bed rest.
A 4-month-old child is at the clinic for a well-baby checkup and immunizations. Which of these actions is most appropriate when the nurse is assessing an infant's vital signs?
- A. The infant's radial pulse should be palpated, and the nurse should notice any
fluctuations resulting from activity or exercise. - B. The nurse should auscultate an apical rate for 1 minute and then assess for any
normal irregularities, such as sinus dysrhythmia. - C. The infant's blood pressure should be assessed by using a stethoscope with a large
diaphragm piece to hear the soft muffled Korotkoff sounds. - D. The infant's chest should be observed and the respiratory rate counted for 1
minute; the respiratory pattern may vary significantly.
Correct Answer: B
Rationale: The nurse auscultates an apical rate, not a radial pulse, with infants and toddlers. The pulse should be counted by listening to the heart for 1 full minute to account for normal irregularities, such as sinus dysrhythmia. Children younger than 3 years of age have such small arm vessels; consequently, hearing Korotkoff sounds with a stethoscope is difficult. The nurse should use either an electronic lood pressure device that uses oscillometry or a Doppler ultrasound device to amplify the sounds.
An infant's respiratory rate should be assessed by observing the infant's abdomen, not chest, because an infant's respirations are normally more diaphragmatic than thoracic. The nurse should auscultate an apical heart rate, not palpate a radial pulse, with infants and toddlers.
The healthcare professional has collected the following information on a patient: palpated blood pressure"?180 mm Hg; auscultated blood pressure"?170/100 mm Hg; apical pulse"?60 beats per minute; radial pulse"?70 beats per minute. What is the patient's pulse pressure?
- A. 10
- B. 70
- C. 80
- D. 100
Correct Answer: B
Rationale: Pulse pressure is the numerical difference between the systolic and diastolic blood pressure readings. In this case, the systolic blood pressure is 170 mm Hg, and the diastolic blood pressure is 100 mm Hg. Therefore, the pulse pressure is calculated as 170 - 100 = 70 mm Hg. Pulse pressure reflects the stroke volume, the amount of blood ejected from the heart with each beat. Choices A, C, and D are incorrect because they do not accurately represent the difference between the systolic and diastolic blood pressure readings provided.
When a sequence of repeated weights is necessary, the healthcare provider should aim to weigh the patient at the same time of day and with consistent clothing. Using a standardized balance or electronic standing scale is recommended for accurate measurements. The patient should remove shoes and heavy outer clothing. It is not required for the patient to always be weighed in undergarments. What is the most appropriate indicator of the patient's overall well-being?
- A. General health
- B. Genetic makeup
- C. Nutritional status
- D. Activity and exercise patterns
Correct Answer: A
Rationale: Weight measurements are essential to assess general health, particularly in monitoring growth patterns. Height and weight recordings are crucial indicators of overall well-being, reflecting the individual's health status. Genetic makeup does not change with weight fluctuations, making it an inappropriate indicator. Nutritional status and activity levels can influence weight but are not as comprehensive as general health in reflecting overall well-being.
A leukemia patient has a relative who wants to donate blood for transfusion. Which of the following donor medical conditions would prevent this?
- A. A history of hepatitis C five years previously
- B. Cholecystitis requiring cholecystectomy one year previously
- C. Asymptomatic diverticulosis
- D. Crohn's disease in remission
Correct Answer: A
Rationale: A history of hepatitis C five years previously would prevent a donor from donating blood for transfusion. Hepatitis C is a viral infection transmitted through bodily fluids, such as blood, causing inflammation of the liver. Patients with hepatitis C may not donate blood for transfusion due to the high risk of infection in the recipient. Cholecystitis requiring cholecystectomy one year previously, asymptomatic diverticulosis, and Crohn's disease in remission are not contraindications for blood donation as they do not pose a risk of transmitting infections to the recipient.