A client with asthma has developed viral pharyngitis. Which of the following findings should the nurse expect?

Correct Answer: C

Rationale: The correct answer is C, negative throat culture. In viral pharyngitis, the infection is caused by a virus, not bacteria. Therefore, a throat culture would be negative as it tests for bacterial infection. Option A is incorrect as petechiae are more commonly seen in conditions like meningococcal sepsis. Option B is incorrect as a WBC count of 16,000/mm3 is more indicative of a bacterial infection. Option D is incorrect as severe hyperemia of the pharyngeal mucosa is more typical of bacterial pharyngitis, not viral.

Correct Answer: A

Rationale: The correct answer is A: Widened QRS complexes. Respiratory acidosis results from inadequate removal of carbon dioxide, leading to increased carbonic acid in the blood and a decrease in blood pH. This acidosis can cause electrolyte imbalances, including hyperkalemia, which can manifest as widened QRS complexes on an ECG due to the effect of high potassium levels on cardiac conduction. Hyperactive deep tendon reflexes (B) are associated with conditions such as hyperthyroidism or hypocalcemia. Bounding peripheral pulses (C) are seen in conditions like aortic regurgitation or hyperthyroidism. Warm, flushed skin (D) is more indicative of conditions like hyperthermia or sepsis.

Correct Answer: A

Rationale: In the context of a client with dehydration, oral health is crucial as dehydration can lead to dry mouth and oral complications. The correct answer, option A, "Remind client to avoid commercial mouthwashes," is within the scope of practice for an LPN/LVN as it involves providing education on avoiding potentially drying agents that could exacerbate oral dryness. Option B, "Encourage mouth rinsing with warm saline," while beneficial for oral health, may require a higher level of assessment and decision-making that is typically within the scope of an RN rather than an LPN/LVN. Option C, "Assess lips, tongue, and mucous membranes," involves a comprehensive assessment that goes beyond the LPN/LVN scope of practice, as it requires advanced clinical judgment and interpretation. Option D, "Provide mouth care every 2 hours while the client is awake," involves direct patient care that may be beyond the scope of practice for an LPN/LVN without specific delegation and supervision, as it requires more frequent monitoring and assessment. Understanding the scope of practice is essential for all nursing roles to ensure safe and effective care delivery. LPNs/LVNs play a valuable role in the healthcare team, but it is important for them to know their limitations and when to involve higher-level providers for certain interventions.

Correct Answer: B

Rationale: In this scenario, the correct action to take is to review the client's morning calcium level (Option B). This is because the client is exhibiting signs of hypocalcemia, which can manifest as decreased blood pressure, heart rate, and facial twitching. Calcium plays a crucial role in cardiac function and neuromuscular excitability, so monitoring calcium levels is essential in this situation. Option A (Reassess the client’s blood pressure and heart rate) could be a temporary measure, but it does not address the underlying cause of the symptoms. Option C (Request a neurologic consult today) is not the immediate priority because the symptoms are more indicative of a metabolic issue like hypocalcemia rather than a primary neurological problem. Option D (Check the client's pupillary reaction to light) is not relevant to the symptoms presented and does not address the potential hypocalcemia. In an educational context, this question highlights the importance of recognizing and responding to electrolyte imbalances such as hypocalcemia promptly. Understanding the clinical manifestations of various electrolyte disturbances is crucial for nurses to provide safe and effective care to their patients. By choosing the correct intervention, nurses can help prevent further complications and promote positive patient outcomes.

Correct Answer: A

Rationale: In the context of a client with diabetic ketoacidosis (DKA), delegating the task of checking the fingerstick glucose every hour to the nursing assistant is appropriate. This task does not require advanced clinical judgment or interpretation of results and falls within the scope of practice for a nursing assistant. Monitoring glucose levels closely is crucial in managing DKA as it helps in assessing the effectiveness of treatment and detecting any fluctuations promptly. Recording intake and output every hour, checking vital signs every 15 minutes, and assessing for indicators of fluid imbalance are tasks that require a higher level of clinical judgment and interpretation, thus should not be delegated to a nursing assistant. These activities involve assessing for subtle changes in the patient's condition, which necessitates a deeper understanding of the pathophysiology of DKA and its potential complications. Educationally, understanding the rationale behind delegation in the context of DKA is essential for nurses to provide safe and effective care. It underscores the importance of matching tasks with the appropriate skill level of personnel to optimize patient outcomes and prevent errors. Nurses need to prioritize tasks based on the complexity and criticality of the situation, ensuring that each team member functions within their scope of practice to deliver comprehensive care.