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Question 1 of 5.

A client was struck on the head by a baseball bat during a robbery attempt. The nurse gives shift report to the oncoming nurse and conveys that the client's current Glasgow Coma Scale score is a '10.' Which other information is most important for the reporting nurse to include?

A. Client's blood pressure was 120/80 mm Hg and pulse was 82/min recently

B. Client's Glasgow Coma Scale score was '11' one hour ago

C. Client believes that the current surroundings are a racetrack

D. Client is allergic to penicillin and vancomycin

Explanation: A decrease in Glasgow Coma Scale score from 11 to 10 in one hour indicates worsening neurological status, possibly due to increasing intracranial pressure, requiring urgent reporting.

Question 2 of 5.

The nurse hears another staff member talking in a crowded elevator about a client on the unit. The client is identified by name and details of illness. What action should the practical nurse take at this time?

A. Report the behavior to the head nurse

B. Report the behavior if it happens again

C. Interrupt the conversation in the elevator

D. Speak to the staff member when he/she gets off the elevator

Explanation: Speaking to the staff member privately after the elevator ride addresses the HIPAA violation discreetly, promoting education and correction without immediate escalation.

Question 3 of 5.

The mother of a 4-month-old infant calls the physician's office reporting that her child has a temperature of 101°F and a rash that is blanchable and doesn't itch. What does the LPN expect will be ordered for this child?

A. Aspirin

B. Ibuprofen

C. Acetaminophen

D. Antibiotics

Explanation: Acetaminophen is safe for fever in infants, addressing the temperature while the non-itchy, blanchable rash is monitored, likely viral.

Question 4 of 5.

A client who has Type 1 diabetes mellitus is admitted for alcohol detoxification. A moderate sliding scale for insulin is ordered. How often should the nurse expect to take glucose levels?

A. Every time medication is administered

B. When the client is symptomatic

C. Before meals and at bedtime

D. Every two hours

Explanation: Sliding scale insulin for Type 1 diabetes requires glucose checks before meals and at bedtime to adjust dosing, ensuring glycemic control.

Question 5 of 5.

The physician has recommended that an adult male be scheduled for a left heart catheterization. The client asks the nurse what a cardiac catheterization is for. What information should be included when responding to this client?

A. During a left heart catheterization, the coronary arteries can be visualized.

B. During a left heart catheterization, holes in the heart walls can be detected.

C. During a left heart catheterization, blood flow to the lungs can be measured.

D. During a left heart catheterization, oxygen levels in the chambers of the heart are measured.

Explanation: Left heart catheterization visualizes coronary arteries to assess for blockages, aiding in diagnosing coronary artery disease.

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