Which assignment should not be performed by the licensed practical nurse?
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Solution
Answer D is correct. A licensed practical nurse should not be assigned to initiate a blood transfusion. The LPN can assist with the transfusion and check ID numbers for the RN. The licensed practical nurse can be assigned to insert Foley and French urinary catheters, discontinue Levine and Gavage gastric tubes, and obtain all types of specimens, so answers A, B, and C are incorrect.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
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Solution
Answer B is correct. The vital signs are abnormal and should be reported to the doctor immediately. Answer A, continuing to monitor the vital signs, can result in deterioration of the client’s condition. Answer C, asking the client how he feels, would supply only subjective data. Involving the LPN, in answer D, is not the best solution to help this client because he is unstable.
Which nurse should be assigned to care for the postpartal client with preeclampsia?
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Solution
Answer B is correct. The nurse in answer B has the most experience with possible complications involved with preeclampsia. The nurse in answer A is a new nurse to this unit and should not be assigned to this client; the nurses in answers C and D have no experience with the postpartal client and also should not be assigned to this client.
Which information should be reported to the state Board of Nursing?
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Solution
Answer B is correct. The Joint Commission on Accreditation of Hospitals will probably be interested in the problems in answers A and C. The failure of the nursing assistant to assist the client with hepatitis should be reported to the charge nurse. If the behavior continues, termination may result. Answer D is incorrect because failure to feed and bathe the client should be reported to the superior, not the Board of Nursing.
The nurse is found to be guilty of charting blood glucose results without actually performing the procedure. After talking to the nurse, the charge nurse should:
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Solution
Answer B is correct. The action after discussing the problem with the nurse is to document the incident and file a formal reprimand. If the behavior continues or if harm has resulted to the client, the nurse may be terminated and reported to the Board of Nursing, but this is not the first step. A tort is a wrongful act committed against a client or his belongings. Answers A, C, and D are incorrect.
The home health nurse is planning for the day’s visits. Which client should be seen first?
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Solution
Answer D is correct. The priority client is the one with multiple sclerosis who is being treated with cortisone via the central line. This client is at highest risk for complications. MRSA, in answer C, is methicillin-resistant staphylococcus aureas. Vancomycin is the drug of choice and can be administered later, but its use must be scheduled at specific times of the day to maintain a therapeutic level. Answers A and B are incorrect because these clients are more stable.
Several clients are admitted to the emergency room following a three-car vehicle accident. Which clients can be assigned to share a room in the emergency department during the disaster?
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Solution
Answer B is correct. Out of all of these clients, it is best to hold the pregnant client and the client with a broken arm and facial lacerations in the same room. The clients in answer A need to be placed in separate rooms because these clients are disruptive or have infections. In the case of answer C, the child is terminal and should be in a private room with his parents
The nurse has just received a change-of-shift report. Which client should the nurse assess first?
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Solution
Answer A is correct. The first client to be seen is the one who recently returned from surgery. The other clients in answers B, C, and D are more stable and can be seen later.
A client has been receiving cyanocobalamine (B12) injections for the past 6 weeks. Which laboratory finding indicates that the medication is having the desired effect?
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Solution
Answer D is correct. Cyanocolamine is a B12 medication that is used for pernicious anemia, and a reticulocyte count of 1% indicates that it is having the desired effect. Answers A, B, and C are white blood cells and have nothing to do with this medication.
The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating:
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Solution
Answer C is correct. The client taking antabuse should not eat or drink anything containing alcohol or vinegar. The other foods in answers A, B, and D are allowed.