Where can you discover an adult apical pulse? - ANSWER Left 5th intercostal
rib, mid-clavicular.
What should the nurse look for if a patient weighs 200 pounds at first but 209
pounds by the second day of admission? - ANSWER Fluid retention
Which posture should be used for a rectal exam of a non-ambulatory patient
with arthritis in both hips? - ANSWER Sims Position
Subjective data includes feelings, perceptions, and reported symptoms.
After examining the patient and using two IDs to provide headache relief, the
nurse administers Tylenol. What do you do afterwards? - ANSWER reevaluate
after 30 minutes.
Which evaluation finding do you detect owing to opioid poisoning in a patient
on a high dose of opioid medication for severe pain? ANSWER respiratory
depression.
What does it mean for a nurse to care for a patient who has a peripheral IV that
is used sporadically for drugs rather than continuously? What should the nurse
do to clean this? - ANSWER Flush with 0.9 saline and lock it.
The nurse performed a head-to-toe axe on the patient. What clinical sign doe
s the nurse find? - ANSWER Bilateral crackles.
, Prior to administering a blood transfusion, the nurse instructs the patient to void
or empty the urine drainage collection container. T/F- ANSWER True, due to
fluid overload.
Should a piggyback IV be hung above or below the primary IV bag? -
ANSWER should be hung above the primary IV bag and not below.
What does it mean if your IV site is bloated and pale? - ANSWER fluid could
have leaked into the interstitial space.
Is serosanguinous drainage abnormal on the patient's first post-operative day? -
ANSWER No, it is typical.
Wound is tunnelling, and the wound bed is not visible. Can the LPN take care
of this? - ANSWER No, not in LPN scope.
What is the proper approach to perform abdominal axe? - Answer: examine,
auscultate, palpate.
What will the LPN use to prime the bloodline? - Answer: 0.9 saline.
Erythema on the vein line where there is an IV. What is it called? - Answer
Phlebitis
Is bilateral crackles a precaution when a nurse applies water axe before
delivering an IV? - ANSWER Yes, fluid in the lungs.
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