1.
You are the RN charge nurse on the medical surgical unit, and you are in charge of delegating assignments for the shift. Which of the following would be the most appropriate to delegate to the LPN/LVN?
Correct Answer
C. A 50 year old patient who is 3 days post op and requires a simple dressing change
Explanation
The most appropriate task to delegate to the LPN/LVN would be the simple dressing change for the 50-year-old patient who is 3 days post-op. This task is within the scope of practice for an LPN/LVN and does not require specialized knowledge or skills. The other tasks, such as administering IV antibiotics, giving IV push medications, and providing discharge teaching to a newly diagnosed diabetic, require a higher level of expertise and should be performed by the RN.
2.
You are caring for a patient who is newly diagnosed with Congestive Heart Failure CHF. Which statement by the patient would indicate that your patient teaching has been a success?
Correct Answer
B. I will conduct a daily weight, keep a log of my daily weight, and report to my doctor immediately any weight gain of 3 or more pounds in one day
Explanation
The statement indicates that the patient understands the importance of monitoring their weight and reporting any significant weight gain to their doctor. This is crucial in managing congestive heart failure as weight gain can be a sign of fluid retention and worsening of the condition. By conducting daily weight checks and keeping a log, the patient is actively participating in their own care and taking necessary steps to prevent complications.
3.
Which statement by the client receiving anticoagulation therapy with Coumadin would indicate a need for further teaching?
Correct Answer
D. If I get a severe headache, worse than any other headache I have ever had in my life, I will take two aspirin, and take a nap, as that should help
Explanation
The statement "If I get a severe headache, worse than any other headache I have ever had in my life, I will take two aspirin, and take a nap, as that should help" indicates a need for further teaching because taking aspirin can increase the risk of bleeding in clients receiving anticoagulation therapy with Coumadin. It is important for the client to understand that they should consult their healthcare provider before taking any medication, especially if they are already on anticoagulation therapy.
4.
Which of the following foods should a patient receiving Coumadin therapy be instructed to eat in moderation?
Correct Answer
A. Spinach and other green leafy vegetables
Explanation
Patients receiving Coumadin therapy should be instructed to eat spinach and other green leafy vegetables in moderation. This is because these vegetables are high in vitamin K, which can interfere with the effectiveness of Coumadin, a medication used to prevent blood clots. Consuming large amounts of vitamin K-rich foods can reduce the medication's ability to thin the blood and increase the risk of clotting. Therefore, it is important for patients on Coumadin to maintain a consistent intake of vitamin K and be cautious about consuming excessive amounts of green leafy vegetables.
5.
A client receiving Lopressor 50mg IV should most importantly have which vital signs checked prior to administration?
Correct Answer
C. Blood pressure, and heart rate
Explanation
Prior to administration of Lopressor 50mg IV, it is most important to check the client's blood pressure and heart rate. Lopressor is a medication used to treat high blood pressure and certain heart conditions. Monitoring the client's blood pressure and heart rate prior to administration is crucial in order to assess their baseline cardiovascular status and determine the appropriate dosage of the medication. This helps ensure the medication is administered safely and effectively.
6.
Which of the following orders is complete, not requiring nurse clarification?
Correct Answer
A. Tylenol 650mg PO q4hours PRN for mild pain
Explanation
The order for Tylenol 650mg PO q4hours PRN for mild pain is complete and does not require nurse clarification because it includes the medication name (Tylenol), the dose (650mg), the route of administration (PO - by mouth), the frequency (q4hours - every 4 hours), and the indication (PRN for mild pain). This order provides all the necessary information for the nurse to administer the medication safely and effectively without needing further clarification.
7.
Which of the following laboratory values is considered critical?
Correct Answer
B. Potassium 2.8 mEq/L
Explanation
A potassium level of 2.8 mEq/L is considered critical because it is below the normal range (3.5-5.0 mEq/L). Low potassium levels can lead to serious complications such as muscle weakness, irregular heart rhythms, and even cardiac arrest. Therefore, immediate medical intervention is required to address the critical potassium level and prevent further complications.