PN Fundamentals 2023

Extract:

Question 1 of 5

Which of the following actions should the nurse take to promote the client's respiratory status? Select all that apply.

A. Encourage the client to splint the abdomen when coughing. B. Administer acetaminophen. C. Administer ondansetron. D. Remind the client to use the incentive spirometer five times per hr. E. Encourage the client to cough and deep breathe. F. Plan to ambulate the client 30 min after the next analgesic is administered.

Correct Answer: A,D,E,F

Rationale: A: Splinting reduces pain during coughing. D: Incentive spirometry prevents atelectasis. E: Coughing and deep breathing clear secretions. F: Ambulation post-analgesic promotes lung expansion.

Question 2 of 5

A nurse is caring for a client who is postpartum. Which of the following documentations should the nurse include in the client's health record?

A. Client instructed on self-care needs. B. Episiotomy approximated. 3 cm (1.18 in) in length. C. Client drank adequate amounts of fluid with meals. D. Oral temperature elevated at 0800.

Correct Answer: B

Rationale: Documenting the status of the episiotomy provides essential information regarding healing and recovery, a priority in postpartum care.

Question 3 of 5

A nurse is preparing to obtain a capillary blood specimen from a client. Which of the following actions should the nurse take? (Select all that apply.)

A. Squeeze the client's finger until a blood drop forms. B. Prick the side of the client's finger. C. Elevate the client's hand above the level of the heart. D. Cleanse the client's finger with an iodine swab. E. Apply clean gloves.

Correct Answer: B,E

Rationale: B: Pricking the side is less painful and safer. E: Gloves prevent contamination and ensure safety.

Question 4 of 5

A nurse on a medical-surgical unit is caring for a postoperative client who reports difficulty sleeping due to noise. Which of the following interventions is appropriate for the nurse to implement?

A. Turn off alarms on bedside monitoring equipment B. Avoid entering the client's room unless requested during the night. C. Conduct staff communications away from the client's room. D. Turn on the client's TV to distract from hallway noise.

Correct Answer: C

Rationale: Conducting staff communications away from the client's room reduces noise and promotes a restful environment.

Question 5 of 5

A nurse is reinforcing teaching with a client who has crutches regarding the use of the three-point gait. Which of the following instructions should the nurse include?

A. Bear weight on the unaffected leg. B. Stand with the crutch tips against the feet. C. Hold the arms straight when walking. D. Keep the crutches at the level of the axillae.

Correct Answer: A

Rationale: In the three-point gait, weight is borne on the unaffected leg while moving crutches and the affected leg together.

PN Fundamentals 2023 | Nurselytic

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ATI LPN

ATI LPN