Here are the Questions to NCLEX Preparation Course - Critical Thinking VI (41-50) -->
41) A- the nursing assistant is allowed to assist client out of bed using Hoyer lift. Catheterization, change of dressing should be done by the LPN/LVN. Providing psychosocial care is done by the RN.
42) A
- suction should be applied only during withdrawal of the catheter, not during insertion. This is to prevent trauma to the mucous membrane of the airway. Therefore choice A requires intervention by the nurse. Whe nursing action is incorrect, it requires intervention.
43) C
- a diagonal figure-of-eight bandaging ensures conical shape of the stump. This will facilitate prosthesis fitting.
Choices A, B, D are incorrect actions by the LPN/LVN when wrapping a stump. Therefore, these actions would require intervention by the nurse.
44) D
- following-up tasks delegated to LVN is a responsibility of the RN. A status report will be used as a basis as to what help is needed by the LPN/LVN.
45) A
-the CNA/UAP is competent in setting up Bryant's traction. Choices B, C (nursing process) will be done by the RN. Choice D will be done by the LVN.
46) D
- ethical dilemmas are addressed by the American Nurses Association's Code for Nurses.
47) A, D, and F
- the RN performs phases of the nursing process. Clients who need assessment, health teachings, evaluation and those with unstable conditions should be cared for by the RN.
Choices B, C, and E will be delegated to the LPN/LVN, the "technical doer."
48) A
- causes of deficient fluid volume include vomiting, diarrhea, conditions that cause increased respiration or increased urinary output, insufficient IV fluid replacement, draining fistulas, and the presence of an ileostomy or colostomy. A client with congestive heart failure or decreased kidney function, or a client receiving frequent wound irrigation, is at risk for excess fluid volume.
49) D
- assessment findings in a client with deficient fluid volume include increased respirations and heart rate, decreased central venous pressure (CVP), weight loss, poor skin turgor, dry mucous membranes, decreased urine volume, increased specific gravity of the urine, increased hematocrit, and altered level of consciousness. The normal CVP is between 4 and 11 cm H2O. A client with dehydration has a low CVP. The assessment findings in option A, B, and C are seen in a client with excess fluid volume.
50) B
- the causes of excess fluid volume include decreased kidney function, congestive heart failure, the use of hypotonic fluids to replace isotonic fluid losses, excessive irrigation of wounds and body cavities, and excessive ingestion of sodium. The client taking diuretics, the client with ileostomy, and the client who requires gastrointestinal suctioning are at risk for deficient fluid volume.
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