NCSBN Practice Questions 76-90
ty ty ty
Anty18tymonth-
oldtyweighingty22typoundstyistyadmittedtytotythetypediatrictyunittywithtyatydiagnosistyoftydehydratio
n.tyAtyreplacementtybolustyoftynormaltysalinetyatty20tymL/kgtyistyorderedtytotybetyadministeredtyintr
avenouslytyoverty40tyminutes.
IntymL/hour,tywhattywilltybetythetysettingtyfortythetyIVtydeliverytysystem?ty-tycorrecttyans-300
Usingtyratiotyproportion:First,tyconvertty22typoundstytotykilogramsty(22/2.2)ty=ty10tykg20tymL/kgty
=ty20tyxty10tykgty=ty200tymL200tymL/40tyminutesty=tyxtymL/60tyminutesty(intyantyhour)200tyxty60ty=ty1
2000/40ty=ty300tymL/hrUsingtydimensionaltyanalysis:20tymL/kgtyxty1tykg/2.2tylbtyxty22tylbtyxty60tymi
n/hrtyxty1/40tyminty=ty300tymL/hr
Thetymothertyoftyaty2tymonth-
oldtybabytycallstyatypediatrician'stynursetytwotydaystyaftertythetyfirsttyDTaP,tyinactivatedtypoliotyvac
cinety(IPV),tyHepatitistyBtyandtyHaemophilustyinfluenzaetytypetyBty(HIB)tyimmunizations.tyShetyr
eportstythattythetybabytyfeelstyverytywarm,tycriestyinconsolablytyfortyastylongtyastythreetyhours,tyan
dtyhastyhadtyseveraltyshakingtyspells.tyWhichtyimmunizationtywouldtythetynursetyexpecttytotybetypr
imarilytyresponsibletywithtythesetyfindings?
A.tyDTaP
B.tyIPV
C.tyHepatitistyB
D.tyHIBty-tycorrecttyans-A
DTaPtyimmunizationtyistyatyvaccinetythattyprotectstyagainsttydiptheria,tytetanustyandtypertussisty(
whoopingtycough).tyThetymajoritytyoftyreactionstydescribedtyintythistyquestiontyoccurtywithtythetya
dministrationtyoftythetyDTaPtyvaccination.tyContraindicationstytotygivingtyrepeattyDTaPtyimmuni
zationstyincludetythetyoccurrencetyoftyseveretysidetyeffectstyaftertyatyprevioustydose,tyastywelltyasty
signstyoftyencephalopathytywithintyseventydaystyoftythetyimmunization.
Atyclienttydiagnosedtywithtyanginatyhastybeentyinstructedtyabouttythetyusetyoftysublingualtynitrogly
cerin.tyWhichtystatementtymadetybytythetyclienttyistyincorrecttyandtyindicatestyatyneedtyfortyfurtherty
teaching?
A.ty"I'lltycalltythetyhealthtycaretyprovidertyiftypaintycontinuestyaftertythreetytabletstyfivetyminutestyapa
rt."
B.ty"Itywilltyresttybrieflytyrighttyaftertytakingtyonetytablet."
C.ty"Ityunderstandtythattythetymedicationtyshouldtybetykepttyintythetydarktybottle."
D.ty"ItycantyswallowtytwotyortythreetytabletstyattyoncetyiftyItyhavetyseveretypain."ty-tycorrecttyans-D
Clientstymusttyunderstandtythattyjusttyonetysublingualtytablettyshouldtybetytakentyattyatytimetyandtyp
lacedtyundertythetytongue.tyAftertyresttyandtyatyfive-
minutetyinterval,tyatysecondtyandtythentyeventuallytyatythirdtytablettymaytybetynecessary.
Thetynursetyistyworkingtywithtyvictimstyoftydomestictyabuse.tyThetynursetyshouldtyunderstandtywhi
chtyoftythesetyfactorstyistyatyreasontywhytydomestictyviolencetyortyemotionaltyabusetyremainstyext
ensivelytyundetected?
A.tyThetyexpensestyduetytotypolicetyandtycourttycoststyaretyprohibitive
,B.tyLittletyknowledgetyistyknowntyabouttybattererstyandtybatteringtyrelationships
C.tyTheretyaretytypicallytymanytyseriestyoftyminor,tyvaguetycomplaints
D.tyFewtypeopletywhotyhavetybeentybatteredtyseektymedicaltycarety-tycorrecttyans-C
Signstyoftydomestictyviolencetyortyemotionaltyabusetymaytynottybetyclearlytymanifestedtyandtyincl
udetymanytyseriestyoftyatyminortycomplaintstysuchtyastyheadache,tyabdominaltypain,tyinsomnia,ty
backtypaintyandtydizziness.tyThesetymaytybetycoverttyindicationstyoftyviolencetyortyabusetythattygot
yundetected.tyThesetycomplaintstymaytybetyvaguetyandtyreflecttyambivalencetyabouttythetydisclo
suretyoftyanytyviolencetyortyabuse.
Thetynursetyistyobtainingtyantyaerobictywoundtyculturetyfromtyatyclienttywithtystagetytwotypressuretyi
njury.tyThetynursetyfirsttyremovestyatygauzetydressingtyandtyobservestyatymoderatetyamounttyoftyp
urulenttydrainagetyontythetydressingtyandtythentythetynursetyperformstyhandtyhygiene.tyWhattyistyt
hetynexttycorrecttysteptyintythetyprocedure?
A.tySwabtythetygauzetydressingtythattywastyremovedtyfromtythetywound
B.tyIrrigatetythetywoundtywithtynormaltysaline
C.tyObtaintyatyculturetybytyrotatingtyatysteriletyswabtyintythetyopentywound
D.tyRemovetywoundtyexudatetyfromtythetywoundtyedgestywithtyatycottontytiptyapplicatorty-
tycorrecttyans-B
Aftertyremovingtythetydressingtyandtyperformingtyhandtyhygiene,tythetywoundtyneedstytotybetyirrig
atedtytotyremovetysurfacetypathogenstybeforetythetynursetycantyobtaintyatywoundtyculture.tyCultur
estyaretynottyobtainedtyfromtywoundtyexudatetyontythetydressingtyortywoundstythattyhavetynottybee
ntyirrigatedtysincetythetyexudatetymaytybetycontaminatedtywithtynormaltyskintyflora.
Thetynursetyistycaringtyfortyatyclienttywhotyistyexperiencingtyfrighteningtyhallucinationstythattyarety
markedlytyincreasedtyattynight.tyThetyclient'stypartnertyaskstytotystaytyatyfewtyhourstybeyondtythetyv
isitingtytime,tyintythetyclient'styprivatetyroom.tyWhattywouldtybetythetybesttyresponsetybytythetynurse
?
A.ty"Yes,tystayingtywithtythetyclienttyandtyorientingtythetyclienttytotythetysurroundingstymaytydecrea
setyanytyanxiety."
B.ty"No,tyyourtypresencetymaytycausetythetyclienttytotybecometymoretyanxious."
C.ty"No,tyittywouldtybetybesttyiftyyoutybroughttythetyclienttysometyreadingtymaterialtythattythetyclienttyc
ouldtyreadtyattynight."
D.ty"Yes,tywouldtyyoutyliketytotyspendtythetynighttywhentythetyclient'stybehaviortyindicatestythattythet
yclienttyistyortywilltybetyfrightened?"ty-tycorrecttyans-A
Encouragementtyoftyatyfamilytymembertyortyatyclosetyfriendtytotystaytywithtythetyclienttyintyatyquiettys
urroundingtycannottyonlytyhelptyincreasetyorientation,tybuttycantyalsotyminimizetyconfusiontyandty
anxiety.tyThetyvisitortycouldtyalsotyreporttytotythetynursetyanytyunusualtyfindingstyoftythetyclient.tyThi
stywouldtybetythetymosttysupportivetyapproachtyfortythistyclient.
ThetyRN,tywhotyistyfunctioningtyastythetychargetynurse,tyneedstytotydeterminetyshifttyassignments
.tyHowtywilltythetychargetynursetydeterminetywhichtyclienttyassignmentstyaretyappropriatetyfortythet
ylicensedtypracticaltynursety(LPN)?
A.tyAsktythetyLPNtyabouttypriortyexperiencetycaringtyfortyclientstywithtysimilartydiagnoses
B.tyDeterminetyhowtymanytynursingtyassistantstyaretyavailabletytotyhelptythetyLPNtywithtyclienttyca
re
C.tyRefertytotythetylisttyoftytechnicaltytaskstyLPNstyaretytrainedtytotyperform
,D.tyReviewtythetyproceduretymanualtywithtythetyLPNtypriortytotymakingtyantyassignmentty-
tycorrecttyans-A
Thetydefinitiontyoftyassignmenttyistythetyroutinetycare,tyactivitiestyandtyprocedurestythattyaretywithi
ntythetyauthorizedtyscopetyoftypracticetyoftythetyRNtyortyLPN/LVN.tyThetyRNtymusttydeterminetythety
needstyoftythetyclientstyandtymaketyassignmentstynottyonlytybasedtyontyscopetyoftypractice,tybuttyal
sotyeducation,tydemonstratedtycompetencytyandtyskilltylevel.tyRegardlesstyiftythetyLPNtyreceive
dtyeducationtyandtytrainingtytotyperformtyspecifictyskills,tythetyRNtyneedstytotydeterminetythetyLPN'
styexperiencetywithtycaringtyfortyclientstywithtysimilartydiagnoses.tyWhiletythetyRNtyistyresponsiblet
yfortyensuringtyantyassignmenttygiventytotyatydelegateetyistycarriedtyouttycompletelytyandtycorrectl
y,tythetyLPNtymusttybetyabletytotyperformtythetyskillstyortytaskstyindependently.
Thetynursetyistycaringtyfortyatyschool-
agedtychildtywithtyatydiagnosistyoftysecondarytyhyperparathyroidismtyaftertytreatmenttyfortychron
ictyrenaltydisease.tyWhichtyserumtylabtydatatyshouldtyreceivetyprioritytyattentiontybytythetynurse?
A.tyOsmolalitytyandtysodium
B.tyBloodtyureatynitrogentyandtymagnesium
C.tyCalciumtyandtyphosphorus
D.tyGlucosetyandtypotassiumty-tycorrecttyans-C
Thetyparathyroidtyregulatestythetycalciumtyandtyphosphorustyserumtylevels.tyCalciumtyandtypho
sphoroustylevelstywilltybetyelevatedtyintyhyperfunctiontyoftythistyglandtyuntiltythetyclienttyistystabiliz
ed.tyTotyrecalltythistyinformationtythinktyoftyatysee-
saw.tyAssociatetythattycalciumtyistyfirsttyintythetyalphabettyandtythustycalciumtyfollowstythetydirectio
ntyoftythetyabnormalityty-tyhypertyortyhypotyfunctionty-
tyoftythetyparathyroid.tyPuttythetycalciumtyontyonetysidetyandtythetyphosphorustyontythetyothertysidety
oftythetysee-saw.
Thetynursetyistycaringtyfortyatyclienttywhotyjusttyhadtyatycentraltyvenoustycathetertylinetyinsertedtyattyt
hetybedside.tyWhichtyoftythesetyassessmentstyrequirestyimmediatetyattentiontybytythetynurse?
A.tyPallortyintythetyextremities
B.tyIncreasedtytemperaturetybytyonetydegree
C.tyInvoluntarytycoughingtyspells
D.tyDyspneatyattyrestty-tycorrecttyans-D
Complicationstyoftycentraltycathetertyinsertiontyincludetypneumothoraxtyandtyhemothorax.tyAirty
embolismtyistyanothertypotentialtycomplication.tyDyspnea,tyshallowtyrespirations,tysuddentysha
rptychesttypaintythattyworsenstywithtycoughingtyortydeeptybreathingtyaretyindicationstyoftypneumot
horax.tyOthertypotentialtycomplicationstyoftycentraltycatheterstymaytyincludetythrombosis,tylocalty
ortysystemictyinfection,tyortyeventycardiactytamponadety(iftythetycentraltylinetyperforatestythetyhear
t).tyWhentyconsideringtythetyoptionstylisted,tythetyclienttywhotyistydyspneictyaftertycentraltylinetyins
ertiontywouldtybetythetygreatesttyconcerntyfortythetynurse.
Thetynursetyistyprovidingtypreproceduraltyeducationtytotythetyclienttypreparingtyfortyatybariumtyene
ma.tyWhattystatementtymadetybytythetyclienttyindicatestyatyneedtyfortyfurthertyeducation?
A.ty"Itywilltyneedtytotydrinktyplentytyoftyfluidstyandtyeattyfoodstyhightyintyfibertyaftertythetyprocedure."
B.ty"Itywilltyusetythetyprescribedtylaxativetybeforetythetyprocedure."
C.ty"Itywilltynottyeattyortydrinktyanythingtyaftertymidnighttybeforetythetyprocedure."
, D.ty"AtybariumtyenematyistyusedtytotyexaminetythetyuppertyandtylowertyGItytracts."ty-tycorrecttyans-
D
Atybariumtyenematyinvolvestyfillingtythetylargetyintestinety(lowertyGItytract)tywithtydilutedtybariumtyli
quidtywhiletyx-
raytyimagestyaretytaken.tyAftertythetyprocedure,tyatysmalltyamounttyoftybariumtywilltybetyimmediate
lytyexpelledtyandtythetyremaindertywilltybetyexcretedtyintythetystool.tyBecausetybariumtyliquidtymayty
causetyconstipation,tyclientstyshouldtyeattyfoodstyhightyintyfibertyandtydrinktyplentytyoftyfluidstytotyhe
lptyexpeltythetybariumtyfromtythetybody.
Atyclienttyadmittedtywithtyhearttyfailuretyistyexperiencingtyseveretyshortnesstyoftybreathtyandtystat
es,ty"Ityfeeltyliketysomethingtyistyterriblytywrong!"tyThetyclienttyistyrestlesstyandtybeginstytotycoughtyu
ptylargetyamountstyoftypinktyfrothytysputum.tyThetyclient'styskintyistyatyduskytygrayishtycolortyandtyth
etyoxygentysaturationtylevelstyhavetydecreasedtyfromty92%tytoty76%tyintythetylasttyhour.tyWhattyistyt
hetyfirsttyactiontythetynursetyshouldtytake?
A.tyChecktyvitaltysigns
B.tyAdministertythetyPRNtyorderedtyoxygen
C.tyCalltythetyhealthtycaretyprovider
D.tyPlacetythetybedtyintyhightyFowler'stypositionty-tycorrecttyans-B
Whentydealingtywithtyatymedicaltyemergency,tythetyruletyistytotyassesstyairwaytyfirst,tythentybreathi
ng,tyandtythentycirculation.tyStartingtyoxygentyistythetypriority.tyThetyothertyactionstyshouldtyalsotyb
etyimplementedtyastyquicklytyastypossible,tyincludingtyactivationtyoftythetyrapidtyresponsetyteam.ty
Thetyclienttyistyexperiencingtyantyacutetyepisodetyoftyfulminanttypulmonarytyedema,tylikelytyastyaty
resulttyoftyatynewtyandtyseveretycardiactyeventtyandtypossibletycardiogenictyshock.tyEmergencyty
assessmenttyandtyinterventiontyistyindicatedtytotypreventtycardiactyarresttyandtypossibletydeath.
Theretyistyantyordertyfortyatycontinuoustylidocainetyinfusiontyattyatyratetyofty4tymg/minutetytotytreattyP
VCs.tyThetyIVtysolutiontycontainsty2tygramstyoftylidocainetyinty500tymLtyoftyD5W.tyThetyinfusiontypu
mptydeliversty60tymicrodrops/mL.
Whattyratetyintymicrodrops/minutetywouldtydeliverty4tymgtyoftylidocaine/minute?tyReporttythetyres
ponsetyusingtyatywholetynumber.ty-tycorrecttyans-60
Dimensionaltyanalysisty(DA):tyRemembertyintyDA,tyyoutyalwaystywanttytotystarttyyourtyequationty
withtywhat'stycalledtyfortyintythetysolution.tyIntythistycase,tyyoutywanttytotyknowtymicrodrops/minute.
microdrops/minutety=ty4tymg/mintyXty1tyg/1000tymgtyXty500tymL/2tygtyXty60tymicrodrops/mLty=ty4ty
Xty500tyXty60/1000tyXty2ty=ty120000/2000ty=ty60tymicrodrops/mLAnothertywaytytotysolvetyfortyX:W
hattyyoutyhave:ty2tygramsty(2000tymg)tylidocainetyinty500tymLtyANDtyyoutyaretyusingtyatymicrodripty
setty(60tymicrodrops/mL)Whattyyoutywant/need:ty4tymgtylidocainetytotyinfuse/minute4tymg/minty
Xty500tymL/2000tymgtyXty60ty(microdrops)/minty=ty60tymicrodrops/minute
Thetynursetyistyreviewingtyclienttyassignmentstyattythetybeginningtyoftythetyshift.tyWhichtytasktycou
ldtybetysafelytyassignedtytotyantyunlicensedtyassistivetypersonty(UAP)?
A.tyStaytywithtyatyclienttyduringtythetyself-administrationtyoftyinsulin
B.tyCleantyandtyapplytyatydressingtytotyatysmalltypressuretyulcertyontythetyleg
C.tyEmptytyatyclient'stycolostomytybag
D.tyMonitortyatyclient'styresponsetytotypassivetyrangetyoftymotiontyexercisesty-tycorrecttyans-C
IftythetyUAPtyhastydemonstratedtycompetencytyintythetytask,tys/hetymaytyemptytyatyclient'stycolost
omytybag.tyThistyistyantyuncomplicated,tyroutinetytasktywithtyantyexpectedtyoutcome.tyThetyotherty
ty ty ty
Anty18tymonth-
oldtyweighingty22typoundstyistyadmittedtytotythetypediatrictyunittywithtyatydiagnosistyoftydehydratio
n.tyAtyreplacementtybolustyoftynormaltysalinetyatty20tymL/kgtyistyorderedtytotybetyadministeredtyintr
avenouslytyoverty40tyminutes.
IntymL/hour,tywhattywilltybetythetysettingtyfortythetyIVtydeliverytysystem?ty-tycorrecttyans-300
Usingtyratiotyproportion:First,tyconvertty22typoundstytotykilogramsty(22/2.2)ty=ty10tykg20tymL/kgty
=ty20tyxty10tykgty=ty200tymL200tymL/40tyminutesty=tyxtymL/60tyminutesty(intyantyhour)200tyxty60ty=ty1
2000/40ty=ty300tymL/hrUsingtydimensionaltyanalysis:20tymL/kgtyxty1tykg/2.2tylbtyxty22tylbtyxty60tymi
n/hrtyxty1/40tyminty=ty300tymL/hr
Thetymothertyoftyaty2tymonth-
oldtybabytycallstyatypediatrician'stynursetytwotydaystyaftertythetyfirsttyDTaP,tyinactivatedtypoliotyvac
cinety(IPV),tyHepatitistyBtyandtyHaemophilustyinfluenzaetytypetyBty(HIB)tyimmunizations.tyShetyr
eportstythattythetybabytyfeelstyverytywarm,tycriestyinconsolablytyfortyastylongtyastythreetyhours,tyan
dtyhastyhadtyseveraltyshakingtyspells.tyWhichtyimmunizationtywouldtythetynursetyexpecttytotybetypr
imarilytyresponsibletywithtythesetyfindings?
A.tyDTaP
B.tyIPV
C.tyHepatitistyB
D.tyHIBty-tycorrecttyans-A
DTaPtyimmunizationtyistyatyvaccinetythattyprotectstyagainsttydiptheria,tytetanustyandtypertussisty(
whoopingtycough).tyThetymajoritytyoftyreactionstydescribedtyintythistyquestiontyoccurtywithtythetya
dministrationtyoftythetyDTaPtyvaccination.tyContraindicationstytotygivingtyrepeattyDTaPtyimmuni
zationstyincludetythetyoccurrencetyoftyseveretysidetyeffectstyaftertyatyprevioustydose,tyastywelltyasty
signstyoftyencephalopathytywithintyseventydaystyoftythetyimmunization.
Atyclienttydiagnosedtywithtyanginatyhastybeentyinstructedtyabouttythetyusetyoftysublingualtynitrogly
cerin.tyWhichtystatementtymadetybytythetyclienttyistyincorrecttyandtyindicatestyatyneedtyfortyfurtherty
teaching?
A.ty"I'lltycalltythetyhealthtycaretyprovidertyiftypaintycontinuestyaftertythreetytabletstyfivetyminutestyapa
rt."
B.ty"Itywilltyresttybrieflytyrighttyaftertytakingtyonetytablet."
C.ty"Ityunderstandtythattythetymedicationtyshouldtybetykepttyintythetydarktybottle."
D.ty"ItycantyswallowtytwotyortythreetytabletstyattyoncetyiftyItyhavetyseveretypain."ty-tycorrecttyans-D
Clientstymusttyunderstandtythattyjusttyonetysublingualtytablettyshouldtybetytakentyattyatytimetyandtyp
lacedtyundertythetytongue.tyAftertyresttyandtyatyfive-
minutetyinterval,tyatysecondtyandtythentyeventuallytyatythirdtytablettymaytybetynecessary.
Thetynursetyistyworkingtywithtyvictimstyoftydomestictyabuse.tyThetynursetyshouldtyunderstandtywhi
chtyoftythesetyfactorstyistyatyreasontywhytydomestictyviolencetyortyemotionaltyabusetyremainstyext
ensivelytyundetected?
A.tyThetyexpensestyduetytotypolicetyandtycourttycoststyaretyprohibitive
,B.tyLittletyknowledgetyistyknowntyabouttybattererstyandtybatteringtyrelationships
C.tyTheretyaretytypicallytymanytyseriestyoftyminor,tyvaguetycomplaints
D.tyFewtypeopletywhotyhavetybeentybatteredtyseektymedicaltycarety-tycorrecttyans-C
Signstyoftydomestictyviolencetyortyemotionaltyabusetymaytynottybetyclearlytymanifestedtyandtyincl
udetymanytyseriestyoftyatyminortycomplaintstysuchtyastyheadache,tyabdominaltypain,tyinsomnia,ty
backtypaintyandtydizziness.tyThesetymaytybetycoverttyindicationstyoftyviolencetyortyabusetythattygot
yundetected.tyThesetycomplaintstymaytybetyvaguetyandtyreflecttyambivalencetyabouttythetydisclo
suretyoftyanytyviolencetyortyabuse.
Thetynursetyistyobtainingtyantyaerobictywoundtyculturetyfromtyatyclienttywithtystagetytwotypressuretyi
njury.tyThetynursetyfirsttyremovestyatygauzetydressingtyandtyobservestyatymoderatetyamounttyoftyp
urulenttydrainagetyontythetydressingtyandtythentythetynursetyperformstyhandtyhygiene.tyWhattyistyt
hetynexttycorrecttysteptyintythetyprocedure?
A.tySwabtythetygauzetydressingtythattywastyremovedtyfromtythetywound
B.tyIrrigatetythetywoundtywithtynormaltysaline
C.tyObtaintyatyculturetybytyrotatingtyatysteriletyswabtyintythetyopentywound
D.tyRemovetywoundtyexudatetyfromtythetywoundtyedgestywithtyatycottontytiptyapplicatorty-
tycorrecttyans-B
Aftertyremovingtythetydressingtyandtyperformingtyhandtyhygiene,tythetywoundtyneedstytotybetyirrig
atedtytotyremovetysurfacetypathogenstybeforetythetynursetycantyobtaintyatywoundtyculture.tyCultur
estyaretynottyobtainedtyfromtywoundtyexudatetyontythetydressingtyortywoundstythattyhavetynottybee
ntyirrigatedtysincetythetyexudatetymaytybetycontaminatedtywithtynormaltyskintyflora.
Thetynursetyistycaringtyfortyatyclienttywhotyistyexperiencingtyfrighteningtyhallucinationstythattyarety
markedlytyincreasedtyattynight.tyThetyclient'stypartnertyaskstytotystaytyatyfewtyhourstybeyondtythetyv
isitingtytime,tyintythetyclient'styprivatetyroom.tyWhattywouldtybetythetybesttyresponsetybytythetynurse
?
A.ty"Yes,tystayingtywithtythetyclienttyandtyorientingtythetyclienttytotythetysurroundingstymaytydecrea
setyanytyanxiety."
B.ty"No,tyyourtypresencetymaytycausetythetyclienttytotybecometymoretyanxious."
C.ty"No,tyittywouldtybetybesttyiftyyoutybroughttythetyclienttysometyreadingtymaterialtythattythetyclienttyc
ouldtyreadtyattynight."
D.ty"Yes,tywouldtyyoutyliketytotyspendtythetynighttywhentythetyclient'stybehaviortyindicatestythattythet
yclienttyistyortywilltybetyfrightened?"ty-tycorrecttyans-A
Encouragementtyoftyatyfamilytymembertyortyatyclosetyfriendtytotystaytywithtythetyclienttyintyatyquiettys
urroundingtycannottyonlytyhelptyincreasetyorientation,tybuttycantyalsotyminimizetyconfusiontyandty
anxiety.tyThetyvisitortycouldtyalsotyreporttytotythetynursetyanytyunusualtyfindingstyoftythetyclient.tyThi
stywouldtybetythetymosttysupportivetyapproachtyfortythistyclient.
ThetyRN,tywhotyistyfunctioningtyastythetychargetynurse,tyneedstytotydeterminetyshifttyassignments
.tyHowtywilltythetychargetynursetydeterminetywhichtyclienttyassignmentstyaretyappropriatetyfortythet
ylicensedtypracticaltynursety(LPN)?
A.tyAsktythetyLPNtyabouttypriortyexperiencetycaringtyfortyclientstywithtysimilartydiagnoses
B.tyDeterminetyhowtymanytynursingtyassistantstyaretyavailabletytotyhelptythetyLPNtywithtyclienttyca
re
C.tyRefertytotythetylisttyoftytechnicaltytaskstyLPNstyaretytrainedtytotyperform
,D.tyReviewtythetyproceduretymanualtywithtythetyLPNtypriortytotymakingtyantyassignmentty-
tycorrecttyans-A
Thetydefinitiontyoftyassignmenttyistythetyroutinetycare,tyactivitiestyandtyprocedurestythattyaretywithi
ntythetyauthorizedtyscopetyoftypracticetyoftythetyRNtyortyLPN/LVN.tyThetyRNtymusttydeterminetythety
needstyoftythetyclientstyandtymaketyassignmentstynottyonlytybasedtyontyscopetyoftypractice,tybuttyal
sotyeducation,tydemonstratedtycompetencytyandtyskilltylevel.tyRegardlesstyiftythetyLPNtyreceive
dtyeducationtyandtytrainingtytotyperformtyspecifictyskills,tythetyRNtyneedstytotydeterminetythetyLPN'
styexperiencetywithtycaringtyfortyclientstywithtysimilartydiagnoses.tyWhiletythetyRNtyistyresponsiblet
yfortyensuringtyantyassignmenttygiventytotyatydelegateetyistycarriedtyouttycompletelytyandtycorrectl
y,tythetyLPNtymusttybetyabletytotyperformtythetyskillstyortytaskstyindependently.
Thetynursetyistycaringtyfortyatyschool-
agedtychildtywithtyatydiagnosistyoftysecondarytyhyperparathyroidismtyaftertytreatmenttyfortychron
ictyrenaltydisease.tyWhichtyserumtylabtydatatyshouldtyreceivetyprioritytyattentiontybytythetynurse?
A.tyOsmolalitytyandtysodium
B.tyBloodtyureatynitrogentyandtymagnesium
C.tyCalciumtyandtyphosphorus
D.tyGlucosetyandtypotassiumty-tycorrecttyans-C
Thetyparathyroidtyregulatestythetycalciumtyandtyphosphorustyserumtylevels.tyCalciumtyandtypho
sphoroustylevelstywilltybetyelevatedtyintyhyperfunctiontyoftythistyglandtyuntiltythetyclienttyistystabiliz
ed.tyTotyrecalltythistyinformationtythinktyoftyatysee-
saw.tyAssociatetythattycalciumtyistyfirsttyintythetyalphabettyandtythustycalciumtyfollowstythetydirectio
ntyoftythetyabnormalityty-tyhypertyortyhypotyfunctionty-
tyoftythetyparathyroid.tyPuttythetycalciumtyontyonetysidetyandtythetyphosphorustyontythetyothertysidety
oftythetysee-saw.
Thetynursetyistycaringtyfortyatyclienttywhotyjusttyhadtyatycentraltyvenoustycathetertylinetyinsertedtyattyt
hetybedside.tyWhichtyoftythesetyassessmentstyrequirestyimmediatetyattentiontybytythetynurse?
A.tyPallortyintythetyextremities
B.tyIncreasedtytemperaturetybytyonetydegree
C.tyInvoluntarytycoughingtyspells
D.tyDyspneatyattyrestty-tycorrecttyans-D
Complicationstyoftycentraltycathetertyinsertiontyincludetypneumothoraxtyandtyhemothorax.tyAirty
embolismtyistyanothertypotentialtycomplication.tyDyspnea,tyshallowtyrespirations,tysuddentysha
rptychesttypaintythattyworsenstywithtycoughingtyortydeeptybreathingtyaretyindicationstyoftypneumot
horax.tyOthertypotentialtycomplicationstyoftycentraltycatheterstymaytyincludetythrombosis,tylocalty
ortysystemictyinfection,tyortyeventycardiactytamponadety(iftythetycentraltylinetyperforatestythetyhear
t).tyWhentyconsideringtythetyoptionstylisted,tythetyclienttywhotyistydyspneictyaftertycentraltylinetyins
ertiontywouldtybetythetygreatesttyconcerntyfortythetynurse.
Thetynursetyistyprovidingtypreproceduraltyeducationtytotythetyclienttypreparingtyfortyatybariumtyene
ma.tyWhattystatementtymadetybytythetyclienttyindicatestyatyneedtyfortyfurthertyeducation?
A.ty"Itywilltyneedtytotydrinktyplentytyoftyfluidstyandtyeattyfoodstyhightyintyfibertyaftertythetyprocedure."
B.ty"Itywilltyusetythetyprescribedtylaxativetybeforetythetyprocedure."
C.ty"Itywilltynottyeattyortydrinktyanythingtyaftertymidnighttybeforetythetyprocedure."
, D.ty"AtybariumtyenematyistyusedtytotyexaminetythetyuppertyandtylowertyGItytracts."ty-tycorrecttyans-
D
Atybariumtyenematyinvolvestyfillingtythetylargetyintestinety(lowertyGItytract)tywithtydilutedtybariumtyli
quidtywhiletyx-
raytyimagestyaretytaken.tyAftertythetyprocedure,tyatysmalltyamounttyoftybariumtywilltybetyimmediate
lytyexpelledtyandtythetyremaindertywilltybetyexcretedtyintythetystool.tyBecausetybariumtyliquidtymayty
causetyconstipation,tyclientstyshouldtyeattyfoodstyhightyintyfibertyandtydrinktyplentytyoftyfluidstytotyhe
lptyexpeltythetybariumtyfromtythetybody.
Atyclienttyadmittedtywithtyhearttyfailuretyistyexperiencingtyseveretyshortnesstyoftybreathtyandtystat
es,ty"Ityfeeltyliketysomethingtyistyterriblytywrong!"tyThetyclienttyistyrestlesstyandtybeginstytotycoughtyu
ptylargetyamountstyoftypinktyfrothytysputum.tyThetyclient'styskintyistyatyduskytygrayishtycolortyandtyth
etyoxygentysaturationtylevelstyhavetydecreasedtyfromty92%tytoty76%tyintythetylasttyhour.tyWhattyistyt
hetyfirsttyactiontythetynursetyshouldtytake?
A.tyChecktyvitaltysigns
B.tyAdministertythetyPRNtyorderedtyoxygen
C.tyCalltythetyhealthtycaretyprovider
D.tyPlacetythetybedtyintyhightyFowler'stypositionty-tycorrecttyans-B
Whentydealingtywithtyatymedicaltyemergency,tythetyruletyistytotyassesstyairwaytyfirst,tythentybreathi
ng,tyandtythentycirculation.tyStartingtyoxygentyistythetypriority.tyThetyothertyactionstyshouldtyalsotyb
etyimplementedtyastyquicklytyastypossible,tyincludingtyactivationtyoftythetyrapidtyresponsetyteam.ty
Thetyclienttyistyexperiencingtyantyacutetyepisodetyoftyfulminanttypulmonarytyedema,tylikelytyastyaty
resulttyoftyatynewtyandtyseveretycardiactyeventtyandtypossibletycardiogenictyshock.tyEmergencyty
assessmenttyandtyinterventiontyistyindicatedtytotypreventtycardiactyarresttyandtypossibletydeath.
Theretyistyantyordertyfortyatycontinuoustylidocainetyinfusiontyattyatyratetyofty4tymg/minutetytotytreattyP
VCs.tyThetyIVtysolutiontycontainsty2tygramstyoftylidocainetyinty500tymLtyoftyD5W.tyThetyinfusiontypu
mptydeliversty60tymicrodrops/mL.
Whattyratetyintymicrodrops/minutetywouldtydeliverty4tymgtyoftylidocaine/minute?tyReporttythetyres
ponsetyusingtyatywholetynumber.ty-tycorrecttyans-60
Dimensionaltyanalysisty(DA):tyRemembertyintyDA,tyyoutyalwaystywanttytotystarttyyourtyequationty
withtywhat'stycalledtyfortyintythetysolution.tyIntythistycase,tyyoutywanttytotyknowtymicrodrops/minute.
microdrops/minutety=ty4tymg/mintyXty1tyg/1000tymgtyXty500tymL/2tygtyXty60tymicrodrops/mLty=ty4ty
Xty500tyXty60/1000tyXty2ty=ty120000/2000ty=ty60tymicrodrops/mLAnothertywaytytotysolvetyfortyX:W
hattyyoutyhave:ty2tygramsty(2000tymg)tylidocainetyinty500tymLtyANDtyyoutyaretyusingtyatymicrodripty
setty(60tymicrodrops/mL)Whattyyoutywant/need:ty4tymgtylidocainetytotyinfuse/minute4tymg/minty
Xty500tymL/2000tymgtyXty60ty(microdrops)/minty=ty60tymicrodrops/minute
Thetynursetyistyreviewingtyclienttyassignmentstyattythetybeginningtyoftythetyshift.tyWhichtytasktycou
ldtybetysafelytyassignedtytotyantyunlicensedtyassistivetypersonty(UAP)?
A.tyStaytywithtyatyclienttyduringtythetyself-administrationtyoftyinsulin
B.tyCleantyandtyapplytyatydressingtytotyatysmalltypressuretyulcertyontythetyleg
C.tyEmptytyatyclient'stycolostomytybag
D.tyMonitortyatyclient'styresponsetytotypassivetyrangetyoftymotiontyexercisesty-tycorrecttyans-C
IftythetyUAPtyhastydemonstratedtycompetencytyintythetytask,tys/hetymaytyemptytyatyclient'stycolost
omytybag.tyThistyistyantyuncomplicated,tyroutinetytasktywithtyantyexpectedtyoutcome.tyThetyotherty
