NC1 SET 2

You have four clients during morning rounds. Who requires immediate assessment?

• Post-op cholecystectomy day 1 requesting assistance to the chair after breakfast

• Pneumonia client now confused with RR 32/min and new use of accessory muscles

• Stable heart failure client who refuses 2 g sodium diet education today

• Hip fracture client whose IV pump is alarming with 'air in line' alert

Heparin infusion is ordered by weight with a nurse-driven protocol. What is the safest first step?

• Start the infusion at the average rate for the unit and adjust later

• Verify weight in kilograms, obtain a baseline aPTT, and program the pump with guardrails

• Mix the bag at bedside to ensure a fresh preparation for the client

• Begin at the maximum rate to reach therapeutic levels sooner

You will insert a Foley catheter using sterile technique. Which step prevents field contamination most directly?

• Tucking the sterile drape beneath the buttocks after donning sterile gloves

• Separating labia with the non-dominant hand and keeping that hand contaminated

• Touching the sterile catheter tip to the meatus to locate the urethra

• Inflating the balloon before urine return to verify placement

A delirious client repeatedly pulls at lines. Which approach is least restrictive and effective first?

• Order bilateral soft wrist restraints with every hourly release

• Place the client in view, reduce stimuli, use a sitter, and offer toileting and needs regularly

• Apply a roll belt and mitts to prevent pulling at tubes

• Discontinue all IV therapy to remove the triggering devices

You are changing a central line transparent dressing using sterile technique. Which actions are correct? Select all that apply.

• Mask the client and the nurse during the dressing change

• Perform chlorhexidine scrub with friction and allow complete dry time

• Stabilize the catheter and avoid advancing or pulling on the line

• Use petroleum gauze beneath the transparent dressing to reduce friction

• Date, time, and initial the dressing and document appearance

A COPD client with chronic hypercapnia is at rest with SpO₂ 86% on room air. What is the best action?

• Withhold oxygen to avoid suppressing the respiratory drive entirely

• Administer titrated oxygen to reach 88-92% and monitor closely

• Apply non-rebreather at 15 L/min for rapid saturation to 100%

• Place the client flat and encourage breath-holding maneuvers

A chest tube dislodges from the client while you are assisting to a chair. What is your priority?

• Apply a sterile occlusive dressing taped on three sides and assess for respiratory distress

• Clamp the chest tube and send the client for an immediate x-ray

• Flush the chest tube with sterile saline and reconnect to water-seal

• Place the client prone and call respiratory therapy for suctioning

Ten minutes after starting a blood transfusion, the client has fever, chills, and flank pain. What is the first action?

• Increase the infusion rate and give acetaminophen for fever

• Stop the transfusion, keep the IV line open with saline, and notify the provider and blood bank

• Flush the tubing with lactated Ringer's and resume once symptoms subside

• Obtain a urine sample after the unit is finished to confirm hemolysis

Which assignment is most appropriate for the LPN on a mixed medical-surgical team?

• Perform the initial admission assessment for a client with chest pain

• Teach a newly diagnosed diabetic to draw up and inject insulin

• Administer scheduled oral medications and perform sterile wound care for a stable client

• Evaluate response to a new IV antihypertensive for dose titration

The tracheostomy patient has visible secretions and diminished breath sounds. What is the correct suction sequence?

• Hyperoxygenate, insert catheter without suction, suction while withdrawing in ≤10 seconds, and reoxygenate

• Attach suction before insertion, suction continuously for 30 seconds, then instill NS

• Instill 10 mL NS, insert with suction, rotate once, and suction on the way in

• Insert, clamp the tube, and maintain negative pressure for two full cycles