A client who has frequent watery stool is admitted to the unit due to dehydration possibly caused by C. difficile. Which nursing action should the charge nurse delegate to an LPN/LVN? A. Giving the ordered metronidazole (Flagyl) 500 mg PO to the client. B. Reconsidering the client’s medical history for any risk factors… Read More »
The clinical instructor directed the student nurse to care for a client whose potassium is 6.7 mEq/L. Which intervention is delegated correctly to the student nurse? A. Give potassium 10 mEq orally B. Give sodium polystyrene sulfonate (Kayexalate) 15 g orally C. Give spironolactone (Aldactone) 25 mg orally D. Assess the… Read More »
You are evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns you immediately? A. The patient has fine bibasilar crackles. B. The patient’s respiratory rate is 8 breaths/min. C. The patient sits up… Read More »
A group of passengers enters the ED with complaints of cough, tightness in the throat, and extreme periorbital swelling. There is a strong odor exuding from their clothes. They report exposure to a “gas bomb” that was placed in the bus terminal. What is the priority action? A. Readily transfer clients and visitors from the area… Read More »
A 25-year-old client comes to the outpatient unit with complaints of diarrhea, abdominal pain, shortness of breath, and epistaxis. Which action should the nurse take first? A. Learn whether the client has had recommended immunizations. B. Ask the client about any recent travel to Asia or the Middle East. C. Have the client… Read More »
The patient with COPD has a nursing diagnosis of Ineffective Breathing Pattern. Which is an appropriate action to delegate to the experienced LPN under your supervision? A. Observe how well the patient performs pursed-lip breathing. B. Plan a nursing care regimen that gradually increases activity intolerance. C. Assist the patient with basic activities of… Read More »
You are initiating a nursing care plan for a patient with pneumonia. Which intervention for cough enhancement should you delegate to a nursing assistant? A. Teaching the patient about the importance of adequate fluid intake and hydration. B. Assisting the patient to a sitting position with neck flexed, shoulders relaxed, and knees flexed.… Read More »
A drunk driver has been in the police station for 48 hours. During the first hours, he had tremors and was feeling anxious and sweaty. Currently, he is experiencing disorientation, hallucination, and hyperactivity. It was noted that the client has a history of alcohol abuse. What is the priority nursing diagnosis? A. Risk for Nutritional Deficit… Read More »
A mother of a 14-year-old client receiving chemotherapy for leukemia calls out to the unit concerning her other child having chickenpox. Which of these actions will the nurse anticipate taking next? A. Plan to admit the client to a private room in the hospital. B. Teach the mother about contact and airborne precautions. … Read More »
When assessing a 22-year old patient who required emergency surgery and multiple transfusion 3 days ago, you find that the patient looks anxious and has labored respirations at the rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? A. Increase… Read More »