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Questions 158

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Question 1 of 5

The nurse is caring for a client with a history of a pleural effusion who is scheduled for a thoracentesis. The nurse should:

Correct Answer: C

Rationale: Sitting upright with arms supported facilitates access to the pleural space during thoracentesis and reduces complications. Sedatives and fluid restrictions are not routine.

Question 2 of 5

Which task should be delegated to the licensed practical nurse?

Question Image

Correct Answer: A, B, D, E

Rationale: LPNs can administer subcutaneous heparin (
A), feed via PEG tube (
B), monitor chest tubes (
D), and perform tracheostomy care (E). Removing a PICC line (
C) requires RN-level expertise due to potential complications.

Question 3 of 5

A family is experiencing changes in their lifestyle in many ways. The invalid grandmother has moved in with them. The couple have a 2-year-old son by their marriage, and the wife has two children by her previous marriage. The older children are in high school. In applying systems theory to this family, it is important for the nurse to remember which of the following principles?

Correct Answer: B

Rationale: Any change in any part of the system affects all other parts.

Question 4 of 5

A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at this time?

Correct Answer: B

Rationale: If awakened first, the child will know that nothing painful will be done without the child being alerted. The ventrogluteal site is a safe site for children because it is a large muscle free of major nerves and blood vessels. The dorsogluteal site is not recommended in children who have not been walking for at least 1 year because the muscle is not fully developed. The parent will be able to offer support and comfort during and after the injection.

Question 5 of 5

The nurse is teaching basic newborn care to a group of first-time parents. The nurse should explain that a sponge bath is recommended for the first two weeks of life because:

Correct Answer: B

Rationale: Sponge baths are recommended until the umbilical cord separates (typically within 1-2 weeks) to keep the cord dry and prevent infection. The other reasons are not the primary rationale for this practice.

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