Description
• A client who is a gravida 1, para 0, is transferred to the recovery room
following a normalvaginal delivery of a healthy newborn. The practical
nurse (PN) observes that the client isshaking uncontrollably and states she
is cold. Which intervention should the PN perform?
a. Take her temperature and assessfor additionalsigns of infection
b. Encourage the client to turn to her left side and administer oxygen by
face mask
c. Elevate her legs in a shock position and apply external heat
d. Apply light, warmed blankets and assure her that this is normal
following delivery
• The practical nurse (PN) is assigned to care for four children.
Which child should beassessed first?
a. 4-year-old who needs to stand to void before going to x-ray
b. 3-year-old who is in isolation with chickenpox lesions and MRSA
c. 2-year-old who is admitted for gastroenteritis and vomiting
d. 18-month-old who has cystic fibrosis and is wheezing
Rationale: A young child with cystic fibrosis who is wheezing is demonstrating
respiratory compromise and should be assessed first. The other children be
assessed after the child withrespiratory distress.
• A client with hypertension complains of a persistent dry cough. The
practical nurse (PN)should tell the client that this is a common side effectof
which daily medication?
a. Spironolactone
b. Losartan
c. Clonidine
d. Quinapril
Rationale: A persistent dry cough is a side effect if the antihypertensive agent
quinapril, anACE inhibitor.
• A female client with immune thrombocytopenic purpura is transferred to
a long-term care facility for physical rehabilitation. To prevent injury, which
action is most importantfor the practical nurse to implement?
a. Assess the client for nerve pain or paralysis
b. Evaluate client's neurologicalstatus after exercising
c. Ensure the client has minimal clutter in the room
d. Monitor the client's blood cell laboratory values
Rationale: Immune thrombocytopenic purpura is manifested by low platelet
count and increased capillary fragility, which place the client at risk for bleeding.
The priority of care during rehabilitation is. To ensure the client’s surroundings
and pathways are free of obstaclesand clutter that may cause tactile trauma or
injury.
• The practical nurse (PN) determines that a client who is one day
postpartum has amoderate amount of lochia rubra and the uterus is
firm, extroverted, and three fingerbreadths above the umbilicus.
Which should be the PN's initial action?
a. Assess the bladder for distension
b. Check the hemoglobin to determine uterine hemorrhage
c. Provide a stoolsoftener for constipation
d. Massage the uterus to decrease atony
• The practical nurse (PN) and unlicensed assistive personnel (UAP) enter a
client's roomand find the client lying on the bed. The PN determines that
the client is unresponsive. Which instruction should the PN give the UAP
first?
a. Bring a glucometer to the room
b. Check the blood pressure
c. Feel for a carotid pulse
d. Obtain emergency help
• When providing oral care to an unconscious client who is a mouthbreather and does not swallow, which action is most important for the
practical nurse (PN) to implement?
a. Use an oral suction catheter in the buccal cavity
b. Inspect the oral cavity using gloved fingers
c. Perform oral cleansing with a sponge toothette
d. Apply a petroleum-based lubricant to the client's lips
• A client is scheduled to receive a sublingual tablet and has di昀케culty
swallowing tablets.Which is the best nursing action?
a. Place the tablet under the client'stongue
b. Crush the medication and administer in applesauce
c. Obtain a liquid form of the medication
d. Place the tablet inside the client's cheek