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Question 1 of 5

The nurse is working on a postsurgical floor with an LPN. A new client has just arrived. Which task is appropriate for the nurse to delegate to the LPN?

Correct Answer: A

Rationale: Taking vital signs is within an LPN’s scope. PICC line flushing, IV morphine, and TPN initiation require RN-level judgment.

Question 2 of 5

A young male client who has recently become a quadriplegic makes a sexually inappropriate comment to the nurse. Which of the following statements by the nurse would be most appropriate?

Correct Answer: A

Rationale: Addressing the inappropriate comment directly sets clear boundaries while maintaining professionalism.

Question 3 of 5

A 70-year-old male who is recovering from a stroke exhibits signs of unilateral neglect. Which behavior is suggestive of unilateral neglect?

Correct Answer: A

Rationale: Unilateral neglect involves ignoring one side, such as shaving only one side of the face.

Question 4 of 5

A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?

Correct Answer: B

Rationale: The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury patients. Assessing and relieving the bladder is the priority after elevating the bed.

Question 5 of 5

The nurse is caring for a client taking vancomycin. The nurse anticipates drawing a peak and trough on this client. Which statement regarding peak and trough levels is correct?

Correct Answer: A

Rationale: The peak is drawn 1 hour after infusion to measure maximum concentration, and the trough is drawn just before the next dose to measure minimum concentration.

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