A nurse working on a busy acute care unit is planning care for a group of clients. Which nursing action best exemplifies the primary focus of the nurse's role?

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LPN Nursing Fundamentals Questions

Question 1 of 5

A nurse working on a busy acute care unit is planning care for a group of clients. Which nursing action best exemplifies the primary focus of the nurse's role?

Correct Answer: D

Rationale: Nursing's primary focus is promoting health and wellness holistically, partnering with clients to address physical, emotional, and spiritual needs. Comforting a client after bad diagnostic results exemplifies this, offering emotional support during distress, reinforcing trust, and aiding coping core to nursing's caring essence. Focusing on procedures prioritizes tasks over people, while adjusting the environment supports care delivery indirectly. Monitoring health status is vital but reactive, not the central focus. Comforting reflects nursing's commitment to the whole person, not just illness, aligning with its mission to foster well-being across diverse settings. This action embodies the nurse's role as a compassionate advocate, pivotal in acute care where emotional needs often peak alongside physical ones, enhancing overall client resilience.

Question 2 of 5

The nurse is planning care for a client with a chronic illness. Which intervention reflects tertiary prevention?

Correct Answer: B

Rationale: Tertiary prevention optimizes life with a chronic illness, reducing its impact post-diagnosis. Teaching strategies for living with it like pacing activities for arthritis helps the client adapt, minimizing disability and enhancing function, a nursing priority. Screening for depression is secondary, detecting new issues, not managing the existing one. An annual flu vaccine is primary, preventing unrelated illness, not addressing the chronic condition's effects. Educating about transmission fits infectious cases, not all chronic ones. This intervention tailored coping reflects nursing's role in rehabilitation, ensuring clients thrive despite limits. For instance, teaching a heart failure client fluid management cuts readmissions, aligning with tertiary care's focus on sustaining quality of life through practical, illness-specific support.

Question 3 of 5

The nurse manager is conducting an educational session for the nurses on non-selective beta-adrenergic blockers ( $\beta$ blockers). How should the nurse manager accurately describe the mechanism of action of these medications? List the options in order from first to last.

Correct Answer: C

Rationale: Non-selective beta-adrenergic blockers (e.g., propranolol) inhibit the sympathetic nervous system's effects on beta₁ (heart) and beta₂ (lungs, vessels) receptors. The mechanism sequence is: (1) Beta₁ and beta₂ receptor sites are blocked (C), (2) Epinephrine and norepinephrine actions are blocked (B), (3) Heart rate and blood pressure are decreased (A), (4) Cardiac workload and oxygen demand decreases (D). Blocking beta receptors (C) is the initial step, preventing catecholamines (B) from binding, which reduces heart rate and vasoconstriction (A), ultimately lowering myocardial oxygen demand (D). Incorrect sequencing, like starting with heart rate reduction, skips the pharmacological basis. The CSV requires one answer, so C is chosen as the foundational step. Rationale: Beta blockade directly inhibits receptor activation, a primary action taught in pharmacology education, leading to downstream effects critical for conditions like hypertension or angina, ensuring nurses understand the drug's systemic impact.

Question 4 of 5

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?

Correct Answer: B

Rationale: Tracheoesophageal fistula (TEF), a rare tracheostomy complication, involves an abnormal connection between trachea and esophagus. Aspiration of gastric contents during suctioning (B) is a definitive sign, indicating esophageal leakage into the airway. Frequent suctioning (A) or excessive secretions (D) are nonspecific. Pink skin (C) reflects good oxygenation, not TEF. B is correct. Rationale: TEF allows gastric contents to enter the trachea, detected during suctioning, requiring urgent intervention like tube adjustment or surgery, distinct from routine secretion issues, per critical care nursing.

Question 5 of 5

The nurse is suctioning a client through a tracheal tube. During the procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action?

Correct Answer: B

Rationale: A 10-beat heart rate drop during suctioning suggests vagal stimulation or hypoxia; stopping the procedure and oxygenating (B) is the next action to reverse this. Notifying the RN (A) or limiting time (D) follows. Continuing (C) risks worsening. B is correct. Rationale: Suctioning can trigger bradycardia via vagal nerve activation or oxygen depletion; halting and oxygenating restores stability, a critical step per airway management guidelines, preventing further cardiac compromise.

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