basic physical care passpoint

When receiving a client assignment, which assignment should the licensed practical nurse (LPN) recognize as being outside of the LPN scope of practice? Select all that apply.

- initiating a blood transfusion - completing an initial admission assessment

A nurse is preparing to administer a preoperative intramuscular (IM) injection a 9-year-old child. Which size needle should the nurse select?

22G, 1-inch

During discharge teaching, a client with a fractured toe asks the emergency department nurse why ice should be applied to the fracture site. The nurse should explain that ice application has which effect?

Relieves swelling by reducing blood flow to the injury site

The nurse is gathering data from a group of clients during clinic visits. Which client does the nurse determine is at the greatest risk for the development of type 2 diabetes?

48-year old client that had gestational diabetes with her second child

The nurse is caring for the following clients in the emergency department. Which client, scheduled for surgery, is a candidate for informed consent?

50-year-old client who is scheduled for elective surgery

The nurse is caring for a client with a fever of 103°F (39°C) due to a respiratory infection. The client states, "I am freezing and I have a terrible headache!" What is the appropriate nursing action?

Administer acetaminophen as prescribed.

A nurse is assigned to care for a client who is experiencing acute pain. How can the nurse be sure the client will have a uniform relief of pain?

Administer the analgesic on a schedule around the clock as prescribed by the primary health care provider.

A nurse is caring for a client who has returned from esophagogastroduodenoscopy (EGD). Prior to offering oral fluids, what is a priority action by the nurse?

Check the gag reflex.

A hospitalized client who has a living will is being fed through a nasogastric (NG) tube. During a bolus feeding, the client vomits and begins choking. Which action is most appropriate for the nurse to take?

Clearing the client's airway

The physician orders hourly urine output measurement for a postoperative client. The nurse records the following amounts of output for 2 consecutive hours: 50 ml (8 a.m.)(0800), 60 ml (9 a.m.) (0900). Based on these amounts, what should the nurse do?

Continue to monitor and record hourly urine output.

Two nurses are working the night shift on a medical unit. The first nurse obtains vital signs on assigned clients. One hour later, the second nurse finds the first nurse asleep in the lounge. What should the second nurse do in this situation?

Discuss the situation with the first nurse, including the safety implications of sleeping on the job.

The nurse is recording a client's complaint of painful urination. When documenting this symptom, the nurse should use which term?

Dysuria

Which task can the licensed practical nurse (LPN) appropriately delegate to the nursing assistant?

Encouraging a client to drink fluids

The nurse is preparing to insert a nasogastric tube. What position would best facilitate insertion?

Fowler's

The physician enters an order into the computer for a client who underwent abdominal surgery 24 hours ago. The order states: "Get client out of bed to chair twice daily." Which action should the nurse take when she transfers the client to the chair?

Help the client sit up and dangle his legs over the side of the bed

A gravida 5, para 1 client is admitted to the labor and birth unit in active labor. She has had no prenatal care but appears to be between 32 and 35 weeks' gestation. She tells the nurse that she thinks her friend gave her a cigarette containing crack cocaine. Which action would be most appropriate for the nurse to do next?

Notify the health care provider and assist with setting up for delivery.

A nurse is caring for a woman who is Rh-negative and experienced a spontaneous abortion. The nurse would expect the health care provider to prescribe which medication?

Rho (D) immune globulin

A nurse caring for a client with acquired immunodeficiency syndrome (AIDS) is working with a nursing student. The student does not attempt to suction or assist with care of the client. Which action by the nurse is appropriate?

Talk to the student to determine the issue.

The nurse is caring for a geriatric client with a history of falls. While evaluating the client's risk of fall, the nurse should collect:

gait and balance information.

A client with terminal breast cancer is being cared for by a long-time friend who's a physician. The client has identified her twin sister as the agent in her durable power of attorney. The client loses decision-making capacity, and the twin sister says to the nurse, "There will be a different physician caring for my sister now. I've dismissed her friend." In response, the nurse should:

abide by the wishes of the sister who is the durable power of attorney agent.

The nurse is obtaining a sterile urine specimen from a client's indwelling urinary catheter. To prevent contamination of the specimen, the nurse should:

aspirate urine from the tubing port, using a sterile syringe.

A nurse is caring for a client who's receiving enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as for residual volume. The purpose of the nurse's actions is to prevent which life-threatening complication?

aspiration

A client with a sprained ankle comes to the emergency department. When bandaging the client's ankle, the nurse should use which technique?

figure-eight

A nurse is conducting an admission assessment with a 23-year-old male client. The client states that he recently became engaged and purchased a house. The nurse concludes that this client is effectually managing which developmental task of Erikson's developmental model?

intimacy versus isolation

The nurse is caring for a client who suffered third-degree burns over 50% of the body. Which medication would the nurse anticipate using to prevent infection in this client?

mafenide acetate

A nurse prepares to put a rigid, comatose client back into bed. The client is currently propped up in a reclining chair that does not have removable arms. Which method should the nurse select as the best way to return this client to bed?

obtain assistance to use a mechanical lift to move the client

A nurse is caring for a client who is recovering from an illness requiring prolonged bed rest. Based on the nursing documentation provided, which procedure would the nurse implement next?

performing active range-of-motion exercises of the legs

A nurse is caring for a confused, older adult client. Which action should the nurse prioritize for this client's care?

promoting safety by protecting from injury

A nurse is caring for clients in a subacute unit. Which client care takes priority?

suctioning a tracheostomy client with oxygen saturation of 90%

A nurse is repositioning a client in bed. What should the nurse do to maintain proper body mechanics?

use a wide stance for support

A nurse is caring for a client who had a transurethral resection of the prostate 1 day prior and is on continuous bladder irrigation. The nurse suspects the catheter is blocked. Which nursing intervention is appropriate?

use sterile technique to irrigate the catheter gently