hesi review

Stomatitis

inflammation of the mucosa of the mouth

Thrombocytopenia

low platelet count

Thrombocytopenia

low platelet count S/S of internal bleeding increased pulse, and respirations, restlessness, pallor, decreased urine output and falling blood pressure Immediately report blood in stool, sputum or urine

49. The LVN administers lactulose to a client. Which client outcome would indicate a therapeutic response?

2-3 soft stools per day

50. The HCP prescribes amoxicillin 60mg PO three times a day for a child who weighs 13lbs. The pediatric dosage range is 20 to 40 mg/kg/day in three equal doses. What is the maximum dosage in 24 hours that should be given?

235 mg 13lbs/2.2 = 5.9kg 5.9 x 40 = 236mg max

49. A child with poison ivy weights 25kg and receives a prescription for diphenhydramine PO 5mg/kg. The medication is available as 125 mg/5 ml solution. How many millimeters should the LVN administer?

5 ml 125/25kg=5

_______________________ the LVN needs to administer a prescription of furosemide (Lasix) oral solution to a child. The prescribed dose is 2 mg/kg. The child weighs 55 lbs. the medication is available in a concentration of 10 mg/ml. The LVN should administer how many ml?

5ml

6. The LVN is taking vital signs on a client who has been treated for melanoma in the past. Which findings would cause the LVN to consult the charge nurse?

A mole that is purple in color

30. A client is admitted to the hospital for a Crohn's disease flare up and severe dehydration. Which findings should the LVN report to the registered nurse and or HCP immediately?

A rigid hard abdomen and elevates WBC count

26. The LVN is taking the temperature of a 5 y/o child with otitis media. During the previous 24 hours, the child's temp readings have ranged from 101.2 -102.F tympanic. Which statement accurately evaluates these findings and should be considered when planning care for the remainder of the shift?

A tympanic temp and oral temp are equally accurate techniques in evaluating a child's fever

29. The LVN is interviewing a male client DX with hypertension. Which finding places the client at the greatest risk for development of cerebral vascular accident (CVA)?

A waistline greater than 40 inches

44. A client DX with emphysema that is oxygen dependent lives alone at home and manages self care with no difficulty. Which finding should prompt the home health LVN to consult the RN case manager?

A weight loss of 5 lbs since the last monthly visit

The LVN is reinforcing teaching about prevention of colorectal cancer. The LVN should include which statements to reinforce the teaching to the client?

A. Decrease the consumption of fat, refined carbohydrates and low in animal fat. B. After the age of 50, a colonoscopy should be done q 10 years C. Increase the consumption of vegetables such as broccoli, cabbage and sprouts D. Exercise a minimum of 3-4 times a week

48. The nurse is preparing a 3y/o full term newborn for discharge home. The baby's mother is HIV positive. For which procedures should the LVN wear gloves? Select all that apply

A. Diaper changes E. Heel sticks for metabolic screening

47. The home care LVN assesses a client who takes digoxin. Which signs, if exhibited by the client, may lead the LVN to suspect digoxin toxicity? Select all that apply

A. GI upset C. Diplopia D. Bradycardia E. Photophobia

46. The LVN facilitates an exercise program for elderly clients with T2D. Which are the most beneficial outcomes that the client may experience as a result of participating in the program? Select all that apply

A. Improve circulation B. Decrease total cholesterol C. Reduce cardiovascular risks

46. 20 minutes after continuous epidural anesthetic is administered, a laboring clients B/P drops from 120/80 tp 90/60 mmHg. Which actions should the LVN take immediately. Select all that apply

A. Notify the RN or anesthesiologists B. Continue to assess the B/P q 5 minutes C. Place client on lateral position D. Turn off the continuous epidural

49. An 83 y/o client DX with T2DM has been admitted to home health care for an ulcer on the heel of the left foot. Which changes in the foot should the LVN expect to find? Select all that apply

A. Pedal pulses will be weak or absent in the left foot E. The client denies any pain in the left foot

45. The LVN is applying the finger probe for continuous pulse oximetry on a client. Which actions should help prevent skin irritation or breakdown? ( select all that apply)

A. Rotate the probe location site every 4-8 hours C. Cleanse with soap and water as needed D. Secure with gauze if the client has allergy to adhesive

47. When should the LVN evaluate the client's pain level?

A. Routinely with measurement of vital signs B. When the client initially complains of pain C. At the beginning and en of shift E. 30-60 minutes after administering of an analgesic

50. A pregnant client is scheduled for an amniocentesis. The client asks the LVN what to expect during the procedure. How should the LVN respond? Select all that apply

A. The nurse will be checking your vitals q 15 minutes D. You will be positioned on your back during the procedure and on your left side after. E. Uterine contractions or cramping following the procedure are normal and should be reported to your HCP

45. The home heath LVN visits the home of an older client. The LVN assesses the environment for fall hazards. Which suggestions made by the LVN may prevent the client from falling? Select all that apply

A. Use night lights C. Place nonskid mat in the shower E. Keep walkways clear inside and outside

31. A 6 month old infant is prescribed digoxin for the treatment of CHF. Which observation by the LVN warrants immediate intervention?

Apical heart rate of 60 bpm

40. One of the campers at summer camp strains his ankle. What action can the nurse take to help reduce the pain

Apply icepack

49. While reviewing a new postpartum client's plan of care, the LVN notes that priority nursing DX is impaired tissue integrity: 4th degree laceration. Based on this nursing DX , which interventions should the LVN implement? Select all that apply

B. Administer prescribed Docusate sodium (colace) D. Medicate client for pain q4-6hrs PRN E. Demonstrates positions of comfort when sitting

74. A client DX with diabetes has a prescription of 5 units of regular insulin and 15 units of NPH insulin. In which order should the LVN prepare t administer the insulin? List in order

B. Perform hand hygiene A. Inspect insulin vials and expiration date E. Inject 15 units of air into NPH F. Inject 5 units of air into regular C. Withdrawal 5 units of regular insulin D. Withdrawal 15 units of NPH

50. An adult client who is withdrawing from alcohol is observed caring on a conversation in an empty room while looking under the bed trying to find a neighbor. What interventions should the LVN implement? Arrange in order

B. Take clients vital signs D. Review the last medications administered E. Administer PRN chlordiazepoxide A. Report the clients behavior to the charge nurse C. Sit quietly with the client

29. A client is prescribed clonidine 0.1 mg/24 hour via transdermal patch. Which client outcome would indicate the medication effective?

B/P changes from 180/120 to 140/70 mmHg

37. An elderly client in a wheelchair wants to return to be after eating breakfast. What assessment is most important for the LVN to consider before assisting the client?

B/P of 88/54. Mm Hg

47. When should the LVN encourage a laboring client to begin pushing? Select all that apply

C. At complete cervical dilation E. At complete cervical effacement and dilation

50. An older adult is admitted with a DX of bacterial pneumonia. The LVN observation of the client will most likely show which signs/symptoms? Select all that apply

C. Tachycardia D. Confusion E. Colored Sputum

75. The LVN received report on their assignment of clients. In which order should the LVN assess these clients? List in order

C. The client with aphasia and right hemiplegia who is scheduled for GT placement today D. the client who has chronic renal disease is scheduled for hemodialysis today and three times weekly B. The client who has had GI bleeding but had a negative guaiac test for the last 3 stools A. The client who is recovering from the left total knee replacement and who ambulated with a walker

44. When talking with a family member about prevention of falls, which of the following recommendations should the LVN include in the discussion? Select all that apply

C. get vision and hearing examinations D. Recommend that the client join a tai chi group/class

60. A 78y/o client with CHF receives digoxin 0.25 mg PO daily. Which observation by the nurse indicates that the medication has been effective?

Clear breath sounds bilaterally

43. A caregiver wishes to discuss end of life issues with the nurse. The caregiver asks the nurse to explain what DNR means. What information is most important for the nurse to provide?

DNR that no efforts to perform life saving CPR

The LVN is observing a nurse performing an assessment of a three y/o near drowning victim. The client presents with abnormal involuntary muscle contractions that cause rigid flexion in the upper extremities, extension of the legs, and plantar flexed feet. Which is the most accurate way to document these findings?

Decorticate posturing

6. Which of the following is the highest priority intervention for the nurse who is working with a child with a phobia?

Decrease fear and anxiety

57. A client DX with Guillain-Barré syndrome is hospitalized. Which finding is most important for the LVN to report to the primary HCP?

Decrease in cognitive status of the client

The LVN reinforcing teaching about developmental changes. Which is true about the sequence in the development of fine and gross motor skills?

Development predictably occurs from the head to the toes

Which S/S from a LVN assessment suggest a client is experiencing a form of stress? Select all that apply

Diarrhea Headaches Palpitations

46. The LVN is assisting a client to ambulated with a cane. Arrange the steps in ascending order from the first task to the last task. All options must be used. A. Have the client lean on cane while moving unaffected leg forward B. Have the client hold the cane in the hand of the unaffected extremity C. Apply a gait belt D. Have the client advance the cane and the affected leg E. Explain the procedure to the client

E.C.B.D.A

4. The LVN is caring for a gravida 4, para 3, with history of rheumatic heart disease, admitted to the antepartum unit in preterm labor at 32 keeps gestation. Which assessment findings indicate the onset of cardiac failure requiring immediate intervention?

Edema, tachycardia, and adventitious lung sounds

39. A 53 y/o client with a known history of heavy alcohol abuse is admitted for emergency surgery following a motor vehicle collision. The LVN should observe for which symptoms that are early indications of alcohol withdrawal?

Elevated B/P anxiety, transient hallucinations, tremors and restlessness

23. A client is DX with acute MI. Which diagnostic laboratory value should the LVN anticipates to be the first to elevate to establish a diagnosis of an acute MI?

Elevated troponin levels

13. The findings of a maternal triple screen test indicated that an 18 week primigravida has an elevated serum alpha-fetoprotein (AFP) level. Which information is best for the LVN to provide?

Elevation of any part of this test indicate the need for further studies

47. The pregnant client, who is 34 weeks gestation, calls the prenatal clinic complaining of cramping pain in her abdomen. After the DX of Braxton-hicks contraction is made, the nurse should give the client which of the following recommendations?

Empty your bladder frequently and change position if these contracts are bothering you

11. During the initial morning assessment, a client denise dysuria but reports dark amber urine. Which intervention should the LVN implement?

Encourage additional oral intake of juices and water

7. The LVN is providing care to a client who is experiencing slight scrotal edema following indirect herniorrhaphy. Which postoperative action is not recommended for this client?

Encourage deep breathing and coughing

41. What nursing intervention is important in preventing postpartum thrombophlebitis?

Encourage early ambulation after delivery

4. The oral temperature of a client with a UTI is 103F. Which intervention should the LVN implement first?

Encourage fluid intake Rational- fluid intake reduces fever

43. The nurse is taking the temperature of a client who is 6 hrs postpartum. The nurse notes that the client temperature is 38C (100.4F). Which intervention should the nurse implement?

Encourage fluids to increase hydration

32. A hospitalized client is receiving continuous NG tube feedings at 90 ml/hour via a small bore tube and an enteral infusion pump. Upon entering the client's room, which action should the LVN take first?

Ensure the client's head of the bed is raised at least 30 degrees

12. A client with angina pectoris has been prescribed nitroglycerin tablets PRN for chest pain. Which statement by the client to the LVN clarify with this client

Ensure to chew the pill completely before swallowing it

33. An older client who resides in a long term care facility is hearing impaired. How should the LVN modify interventions for this client?

Face the client and speak in a normal tone of voice

The effects of long term unrelieved stress on the human body has been associated with which physiological effects? Select all that apply

Fatigue Central obesity Amenorrhea

37. The nurse has experienced a busy shift and has been assigned an UAP to assist with the assignment. Which of the following tasks could the nurse delegate to the UAP? Select all that apply

Feed client who needs assistance Measure and document vital signs Perform morning hygiene care

39. The home health LVN is visiting with a client who has a history of second degree heart block and pacemaker placement 6 months ago. Which symptom compliant by the client would be indicative of pacemaker failure?

Feeling of dizziness

16. A client is status post 48 hours a colon resection. Which finding requires the most immediate intervention by the LVN?

Fever of 102F (39.9C) and chills

69. Which foods should the LVN encourage a client to eat to increase their potassium intake? Select all that apply

Flounder (fish) Sweet potatoes Milk Cantaloupe

6. The LVN is caring for a dyspneic client whose oxygen saturation rate is currently 95%. What position is best for this client?

Flowers with both legs supported

7. A depressed client whose judgement is poor and whose thoughts are disorganized tells the LVN the insist on leaving the hospital 1 day after admission. Which documentation in the client medical record suggests that the client is unable to safely care for basic needs? The client

Forgot to turn off the stove several times in the last month

48. Which of the following clients is at highest risk for laryngeal cancer? A client who

Has chewed tobacco for 20 years

50. A client DX with a brain tumor is receiving radiation beam treatment to the right frontal area. The LVN should observe this client for which problem during the early post therapy days?

Headache Inflammation of the surrounding brain tissue, swelling, headache and fatigue

24. Which nursing diagnosis has the highest priority that the LVN should identify when planning care for a client with an indwelling urinary catheter?

High risk for infection

The LVN is performing a focused assessment on an 86 y/o client. Which finding is the LVN likely to observe as a result of age related changes?

Hypoactive bowel sounds

34. A client who is experiencing paralysis of the left arm curses at the LVN and, using the right arm, throws a hairbrush against the wall. How should the LVN respond?

I can see you are upset, i want you to know I am a good listener

Which action should the LVN do while assisting during preoperative management of a child with intestinal bleeding?

Identify and report the hematochezia in stools

46. The nurse is caring for a client who just had a cardiac catheterization. The client insist on getting up to go to the bathroom to urinate immediately when brought back to the room. Which of the following wold be the nurses best response?

If you bend your leg, you will risk bleeding from the insertion site. It's an artery, and could lead to complications

54. The LVN administer cyclobenzaprine to a client. Which outcome would indicate a therapeutic response?

Improved range of motion during PT exercises

28. The LVN educates the older client about a new hearing aid. Which instruction is the most important for the LVN to give the client about care of the new hearing aid?

Inform client to remove before bathing

33. Which action shouldd the LVN implement to ensure the eye ointment is distributed evenly across the eye and lid margin?

Instill the ointment along the LOWER inner edge of the eyelid from the INNER to the outer canthus.

8. A client DX with osteoarthritis. Which intervention should the LVN implement to help relieve joint pain and stiffness?

Instruct the client to take an analgesic before walking daily

3. Following an open reduction of a fractured femur, a client is placed in skeletal traction. Based on the nursing diagnosis of " potential impairment of skin integrity relate to immobility," which nursing intervention should the LVN implement?

Lubricate the hands, slide them under the client, and give back care

26. An elderly client who attends an adult day care program and is wheelchair- mobile and has redness in the sacral. Which information is most important for the LVN to provide?

Make sure client changes positions at least every hour

17. A client DX with diabetes complains to the LVN of decreased tactile sensation in their feet and feelings like their feet are on fire sometimes. Which abnormal laboratory finding should the LVN identify that indicates that the client with diabetes needs further evaluation for diabetic nephropathy?

Microalbuminuria

Which should the LVN include when reinforcing teaching to a client with end stage renal disease?

Monitor B/P and weight

19. Which of the following should the nurse plan to do in order to maintain normal glucose levels in a client receiving TPN therapy?

Monitor blood glucose q 4-6 hrs depending on the clients acuity and follow regular insulin sliding scale

4. When the client is at high risk for suicide, which action is of highest priority to the nurse?

Monitor the clients location and behavior constantly

33. A 78 y/o client has been admitted to the medical unit with fever. Of 103F. The client is lethargic and disoriented to time and place. What is the best nursing intervention at this time?

More the client to a room close to the nursing station and frequently check on the client

43. The HCP recommenced the OTC expectorant Guaifenesin for a client who has a dry, nonproductive cough and congested nasal passages. The client reports that they usually have a glass of wine with dinner nightly. Which information should the LVN provide to this client?

Notify the HCP if the cough last longer than 7 days

43. The spouse of a client with terminal cancer provided the LVN with a copy of the clients living will. What action should the LVN take?

Notify the HCP of the client's wishes

The UAP is assisting a client getting into the shower. The charge nurse answers a call from the fracture clinic to immediately send a UAP's other assigned client to the clinic. Which action should the LVN take?

Notify the delegating nurse of the current request from the fracture clinic

19. A client has developed oral thrush. Which pharmacological agent should the LVN expect to be prescribed?

Nystatin

33. The parent of a 4 y/o often observes his child at day care via a video camera hookup to his computer. The parent tells the LVN at the day care center that the child frequently eats with her fingers rather than with utensils. How should the LVN respond?

Offer reassurance that this behavior is normal but that the chid can now be taught how to use utensils

45. The nurse anticipates the client with a gastric ulcer to have pai

One half to one hour after a meal

27. The LVN has been assigned a client with a history of COPD who has been admitted to the hospital with a medical DX of pneumonia. Which intervention poses the greatest risk of respiratory depression for a client with a history of COPD should the LVN determine is most significant in the development of this client's COPD?

Oxygen administration via nasal cannula 4L/minute

25. An adult client is receiving oxygen at 6 l/min. The client asks the nurse why the oxygen is running through bubbling water. What should be included in the nurses reply?

Oxygen is very drying to tissue, the water humidifies it

6. The older client verbalizes to the LVN that he feels a lack of control over his life. The family member who came with the client states that his father has been exhibiting increased passive behavior and an unwillingness to participate in family functions. What word best describes this client's behavior?

Powerlessness

27. A mother who is positive for HIV virus delivers a 7lb boy. Which intervention should the LVN initiate to prevent transfer of the virus to the infant?

Prevent breastfeeding but encourage rooming in

15. A client DX with RA is prescribed splints for night time use. Which statement by the client demonstrates to the LVN an accurate understanding of the use of the splints?

Prevent deformities

15. As part of the preoperative plan of care for a client who is scheduled for a repeat c-section, the LVN plans to administer the nonparticulate antacid sodium citrate by mouth. What is the purpose of administering this drug preoperatively?

Raise the gastric ph to above 2.5

33. The client DX with bipolar 1 disorder is an inpatient locked unit. The client begins to yell loudly at another client who is also siting in the day room. In order to provide a safe environment for both clients, the nurse should take which action?

Redirect the client in a calm, firm, non defensive manner

3. After experiencing a TIM, a client is prescribed aspirin, 325 mg PO daily. The nurse should teach the client that this mediation has been prescribed to

Reduce the chance of blood clot formation

11. A client with vaginal discharge and pruritus is DX a yeast infection (candidiasis) and is prescribed a 7 day course of intravaginal tioconazole. What information should the LVN provide to the client about using this form of medication?

Remain recumbent for 5 to 15 minutes after insertion of the medication

68. Which interventions should the LVN implement to decrease the possibility of the client developing hypercalcemia? Select all that apply

Remind the client to ambulate around the room at least three times a day Increase fluid intake.

39. Which instruction is most important for the LVN to provide a client before the client leaves the unit to have a MRI performed?

Remove all metal objects from the body

29. Code red (fire) has been announced on the hospital unit. What is the nurses first response?

Remove clients in danger from the fire

The LVN recognizes signs that a 9 month old toddler may be living in an abusive home. Which action is the primary for the LVN?

Report the suspected abuse to local authorities

36. A client who become angry while waiting for a supervised smoke break loudly insist on going outside now. Which intervention is best for the LVN to implement?

Review the schedule of outdoor breaks with the client

31. A mother asks the pediatric nurse about wat she should begin to feed her 6 month old infant. The correct response is

Rice cereal is the first solid introduced that is least allergenic of the cereals.

When preparing a client for non stress test, the LVN should play the client in which position?

Semi-flowers

33. Which maternal behavior is the LVN Maoist likely to see when a new mother receives her infant for the first time?

She receives the infant an touches the infants face with her fingertips

3. The LVN observes a client who is sitting alone and mumbling. How should the LVN document this finding?

Sits alone and mumbles to self

46. The LVN administers two newly prescribed mediations, isosorbide denitrate ( a nitrate) and hydrochlorothiazide (a diuretic) to a client. What instructions should the LVN reinforce with the client in regard to these medication?

Slowly rise from sitting to lying down

42. A client receiving a unit of PRBC begins to complain of chills, temp 101.4F, pulse is 185 and B/P 80/50. The nurse should do which of the following

Stop the transfusion and flush the line

19. Which DX results would you expect to find in the client who has been newly DX as having AIDS?

T cell count of 400 Normal T cell count 1500-4000

33. When caring for a client with head trauma, the nurse notes a small amount of clear, watery fluid oozing from the clients nose. What should the nurse do?

Test the nasal fluid for glucose

1. A 15 y/o male with mild mental retardation who is hospitalized for minor surgery tells a female LVN "wow! You have big ones! Which response is best for LVN to make?

That language is not permitted

31. An 11 y/o boy is admitted after being hit in the head with a baseball during a little league game. Which is most important for the LVN to explore during history taking?

The LOC exhibited after the injury

9. A client is taking Epstein Alfa (Epogen) for treatment of anemia related to chronic renal disease. What clinical finding reveals to the nurse that this medication is working effectively?

The clients hematocrit is in the established target range at 33%

22. The LVN educates the client DX with Parkinson's about levodopacarbidopa. Which instructions about this medication should the LVN include in the client's discharge teaching plan?

The clients urine might be bright orange

37. The water seal chamber of the patients chest drainage set up has stopped fluctuating. The chest tube has been in place for 4 days, and the patient is resting comfortably. What is the most probable cause for the development?

The patients lung has reexpanded

31. A daughter of a client DX with Alzheimer's reports that the client has recently begun refusing to eat. The client recently started taking rivastigmine tartrate. What instructions are instructions are important for the nurse to provide the clients daughter?

The prescriber should be notified about this adverse effect of the medication right away

41. The daughter of a client DX with Alzheimer's disease reports the the LVN that her mother has recently lost her appetite and refuses to eat. The client was recently prescribed rivastigmine tartrate. What instructions are important for the LVN to provide to the client's daughter?

The prescriber should be notified if there is weight loss or an increase loss of appetite

25. The elderly client DX with pulmonary embolus is taking warfarin 5 mg daily. The LVN notes that the most recent INR value is 5.0. Which intervention should the LVN anticipate?

The provider will decrease the dose of warfarin Rational-INR therapeutic range is 2 to 4.5

38. A client in the immediate postoperative period is prescribed morphine via a patient controlled analgesia (PCA) pump. Which finding should the LVN consider the highest priority in this client?

The rate and depth of the clients respiration

30. Following a vaginal delivery, a postpartum client complains of severe cramping after breastfeeding her newborn. Which explanation describes the most likely reason for the clients pain?

The release of oxytocin hormone

20. An extremely agitated client with multiple drainage tubes and an IV line is restrained in bed with wrist and ankle cuffs. A female member expresses concern and ask for an explanation. What is the best "initial" response by the nurse?

The restraints are temporary safety precaution and will be removed as soon as possible when the agitation lessens

The client DX with active pulmonary TB has been prescribed rifampin and isoniazid therapy. The client asks the LVN "How log do I have to take the medication?'' The LVN should respond with which statement?

The typical prescription for this treatment program is 6-9 months

36. A 2 day postpartum client informs the nurse, " Something is wrong with my milk, its yellow" which of the following statement by the nurse is most appropriate?

The yellow fluid is normal and is called colostrum, a premium. It is full of nutrients and wonderful for the baby to drink

32. A child with a confirmed DX of appendicitis has been scheduled for an emergency appendectomy. Suddenly, the child states his pain is much less. The best interpretation of this is that

There is a possibility the appendix has ruptured

47. The client has a chest tube attached to portable chest drainage system. Four hours after the chest tube is inserted the nurse notes there is no bubbling in the water seal compartment. What is the most likely explanation for this?

There is an obstruction in the tubbing coming from the pleural cavity

10. A client admitted with extensive burns cries during a dressing change and says " why are all of you torturing me like this?" I Just want to die" which response by the LVN is best?

These treatments must seem like torture to you, but we want to help you recover

29. The nurse planning care for a client who suffered a CVA with residual dysphasia would write on the care plan to avoid doing which of the following during meals?

Thin liquids

The LVN recognizes which adverse effect on the skin associated with the use of topical steroids?

Thinning (atrophy)

31. Following hip replacement surgery, an elderly client's position is changed every 2 hours which physical characteristics of aging contributes to an increase risk for complications?

Thinning of the skin, with loss of elasticity

24. A new mother has delivered her first baby vaginally and says to the LVN, i saw the baby in the recovery room. The baby sure has a funny looking head. The best response by the LVN is best?

This is normal. The head will return to a round shape within 7-10 days

6. The LVN is obtaining the medical history of a client starting a new prescription for conjugated estrogens PO daily. Which medical condition is not treated by this medication?

Thromboembolic disease Side effects stroke, pulmonary embolism and MI

What are the reasons LVN should manage professional stress?

To avoid nurse burnout To safeguard client safety To reduce compassion fatigue

59. In order to provide culturally competent care, what act must the LVN do first?

Understand one's own views in addition to the client's

34. The CDC and prevention has issued guidelines for health care workers in relation to protection from HIV. The LVN who suspects they maybe pregnant is assigned a client who is HIV+. What action should the LVN implement?

Wear gloves when coming in contact with blood or body fluids of a client

16. Which of the following actions taken by the nurse is specific to caring for a client with methicillin resistant straphylococcus aureus (MRSA)?

Wearing gloves when taking vital signs

19. A client asks the LVN what type of food is the best to eat reduce their chances of getting colon cancer. Which type of food should the LVN suggest to the client?

Whole grains

45. The son of an 80 y/o confused client has asked the the nurse to use a restraint to keep his mother in bed. He fears that she will fall while in the hospital. The nurses best response would be

Why don't wee put the bed in the lowest setting and put a mattress on the floor next to the bed?

27. A urinary catheter has been in place for several days, the dr. Has ordered a urine culture and a sensitivity to be done. Which action by the nurse would be appropriate?

Wipe the port hole with alcohol, and aspirate the urine with a sterile needle and syringe.

7. A client with schizophrenia is admitted to the psychiatric unit. As the nurse approaches the client with medications, he refuses it, accusing the nurse of trying to poison him. The nurses best response would be to tell him that

You may decide if you want to take the medication by mouth or injection, but this medication will help you

Tinea pedis

athlete's foot

12. The parents of a 7 month old infant with spastic cerebral palsy bring him to the pediatric clinic. Which symptom reported by the parents warrants immediate intervention by the LVN?

Choking while being fed

34. A client who had a chest tube removed 2 hours previously is now experiencing dyspnea and tachypnea. What action should the LVN take first?

Raise the head of the bed

20. The LVN should take the vital signs of a 4 month old child in which sequence to collect the most accurate results

Respiratory rate Heart rate Axillary temperature

11. The nurse is instructing a client who has been started on iron supplements. In order to increase absorption of the iron, the nurse suggest the client take them with which of the following

OJ

1. When observing an older client with dementia for symptoms of sundowning syndrome, it is most important that the LVN assess which findings?

Observe for agitation at the end of the day

19. The LVN is caring for an infant with pyloric stenosis. What nursing intervention should be included in the preoperative period?

Observe for projectile vomiting Contribute to metabolic alkalosis

41. The nurse is preparing to give the client 4 mg of morphine sulfate. The nurse finds morphine 10 mg per 2 ml in the narcotic cabinet. How many mls of medication would the nurse prepare? Enter numeric value only

0.8 4/10=0.4x2ml=0.8

14. A 67 y/o client is discharged from the hospital with a prescription for digoxin 0.25 mg daily. Which instructions by the LVN is correct?

Do not take the medication if the heartbeat is irregular or slow pulse Below 60 bpm

44. Which of the following actions demonstrated by the client indicates an understanding of the proper administeration techniques for ophthalmic solutions?

Do not touch the tip of the dropper to the eye or any other object

30. The nurse would give which instruction regarding preprocedure care to a woman who is scheduled for mammogram?

Do not use any deodorant or lotions on the chest or underarms before the mammogram

7. The LVN is caring for a child with acute respiratory condition. When the LVN is monitoring for impending respiratory distress, what sign is the child likely to exhibit first?

Restlessness

31. A client DX with CHF has developed increasing pedal edema and pulmonary edema. What dietary modification is most important for the LVN to reinforce with this client?

Restrict salt and fluid intake

38. A client is status post bowel resection and a NG tube attached to low intermittent suction. The client complains to the LVN of abdominal distention and nausea. What action should the LVN take first?

Assess the NGT drainage in the collection container

2. A male client is seen in the clinic for benign prostatic hypertrophy (BPH). Which intervention is essential for the LVN to include in the client;s visit?

Assess the client for urinary hesitancy and weak or split urinary stream

The RN is organizing workload assignments for 2 UAP and one LVN for 12 clients. The LVN should anticipate the nurse to implement which assignment?

Basic care of 6 clients to each UAP, with medications and treatments to the LVN

11. During a prenatal visit, the LVN discusses with a client the effects that smoking has on a fetus. Which statement is the most characteristics of an infant whose mother smoked during pregnancy?

Lower initial weight documented at birth

What actions should the LVN implement when taking a telephone order?

Sign, date and time the order and document that is was a phone order Repeat back to the HCP the order as it was recorded Verify the ID of thee person calling in the order

42. A nurse is caring for a client with an unstable gait. The client was found by the unlicensed assistant on the floor. The client is complaining of hip pain. How should the nurse document this incident?

Complete an incident report, and document the fall in the clients chart

10. The nurse empties 100ml of sangineous drainage from a hemovac drain in the elderly clients hip after a total hip replacement. What other actions regarding the drain should the nurse take?

Compress and close the drain to assure suction

13. The LVN is instructing a client in the proper use of a metered dose inhaler. Which instructions should the LVN reinforce to the client to ensure the optimal benefits from the drug?

Compress the inhaler while slowly breathing in through the mouth

The LVN is reinforcing teaching to family members of a client with psychosis. The LVN cautions the family members that the client may have command hallucinations. What is the primary concern regarding this type of hallucinations?

Suicide

67. A client DX with fluid volume deficit. Which findings would the LVN document consistent with fluid volume deficit? Select all that apply

Tachycardia Cool skin Decreased urine output Increased thirst

14. The nurse is assisting with gathering information for a heath history of a clinet being admitted for surgery. Which of the following questions would best prevent an adverse reaction during hospital admission?

Do you have any allergies to food, medication, latex or tape?

41. A 43 y/o female client status post thyroidectomy for Addison disease is prescribed a thyroid replacement hormone. Which S/S are associated with thyroid hormone toxicity and should be reported promptly to the HCP?

Tachycardia and chest pain

42. The nurse observes that a 3 y/o child combines words in short phrases and understands the concepts of hot and cold and big and little. Which intervention should the LVN implement?

Document that the child's expressive speech is age appropriate

7. The client has end stage Alzheimer's disease and is admitted into hospice care. Which statement indicates the philosophy of hospice care?

To allow the client to die with as much comfort and dignity as possible

Which is the best method the LVN can reinforce teaching to a mother of an infant to minimize the occurrence of diaper rash?

To change the diaper as soon as it is soiled

19. The LVN is using the Glasgow Coma Scale to perform a Neurological assessment. A comatose client winces and pulls away from a painful stimulus. What action should the LVN take next?

Document that the client responds to painful stimulus

41. A client who is 34 weeks gestation has been having contractions every 10 minutes. In addition to instructing her to lie down and rest while continuing to time contractions, the nurse should also tell her to

Drink 3-4 cups of water

7. A diabetic client tells the nurse that he has some early signs of hypoglycemi. The nurse recommends to the client to

Drink a glass of OJ

11. The LVN emphasizes ways to prevent constipation to the elderly client. Which instructions should the LVN include in the client's discharge teaching plan?

Drink several glasses of water throughout the day

39. The LVN is teaching a primigravida about breastfeeding. Which finding requires follow-up? The client

Drinks one or two beers each evening to relax

35. A new mother is having trouble breastfeeding her newborn son. He is making frantic rooting motions and will not grasp the nipple. Which intervention should the LVN implement?

Encourage the mother to stop feeing for a few minutes and comfort the infant

31. The nurse is preparing to enter the room of a client with pneumonia caused by penicillin-resistant streptococcus pneumonia (PRSV). The client has a tracheostomy and requires suctioning. Put the following PPE in order of donning

Gown Mask Eye protection Gloves

62. A client DX with ulcerative colitis (UC) asks the LVN why they are prescribed a low-residue diet. which is the most appropriate response?

To cleanse and evacuate stool from the large colon To reduce the amount and frequency of stool

6. A 25y/o client has a positive pregnancy test. One year earlier she had spontaneous abortion at 3 month's gestation. What is the description that the LVN should use to document gravida and parity in this clients medical record?

Gravida 2 para 0

49. The pregnant client reports that she has 3 y/o child at home who was born at term, had a miscarriage at 10 weeks gestation, and delivered a set of twins at 28 weeks gestation that died within 24 hours. In the prenatal record, the nurse should record.

Gravida 4, para 2

36. The LVN attempts to help a teenage client with her feelings following a spontaneous abortion at 8 weeks gestation. What type of emotional response should the LVN anticipate?

Grief related to her perception about the loss of this child

17. An immobile client is prescribed dalteparin subcutaneously and has been receiving the medications for 5 days. Which finding indicates that the LVN should hold the prescribed dose?

Guaiac positive stool

44. A family has just learned that a member of the family has been given a terminal DX. They are very upset and are loudly expressing their anger in the hall. Which action should the LN take first?

Guide the family to an empty room for privacy

48. The LVN is preparing to administer a prescribed dose of digoxin 125 mcg PO. The medication available is 0.25 mg per tablet. How many tablets should the LVN administer? (Round to the nearest tenth)

0.5 (125 mcg x 1mg/1000 mcg x 1 tablet/ 0.25 mg = 0.5 tablet)

____________ The LVN prepares to administer ampicillin ( Ampicin) 750 mg IV. The medication is a available in a concentration of 1 g/ml. The LVN should prepare how many ml of medication? Enter numeric value only, rounded to the nearest tenth)

0.8 1000x15/750=0.75 rounded to the nearest tenth 0.8

47. A client DX with a herniated disc is prescribed hydrocodone/ acetaminophen 10mg/300 mg PRN q 4-6 hours. As the LVN enters the clients room to administer their requested medication, the client is seen talking and laughing with his visiting family. Which action should the LVN implement?

Administer the requested analgesia

11. A child is brought to the pediatric ambulatory clinic with a runny nose and a low grade fever. He is scheduled to receive the MMR and DTap vaccines. What should the nurse do at this time?

Administer the vaccines as scheduled

57. The nurse is caring for a client who has newly prescribed insulin aspart 7 units subcut prior to each meal. Which nursing intervention has the highest priority when planning the client's. Care?

Ensure that the client's meal will be available within the next 15 minutes before administration of insulin

65. Which of the following actions demonstrate to the LVN that the client understands the correct procedure administration of a metered dose inhaler. (MDI) select ally that apply

1. Shake the inhaler 2. Attach the canister of medication to the mouthpiece 3. Client should let their breath out through the mouth to empty the lungs 4. Use a spacer attachment and place the mouthpiece in the mouth 5. Close the lips around the mouthpiece 6. Inhale medication and holding the breath for 10 seconds

35. The nurse has an order to insert a NGT into the stomach of an assigned client. Place in order the steps that the nurse would follow to complete the procedure

1. Sit client in upright High flowers position 2. Place distal end of the tube at tip of nose and measure to earlobe and then to xiphoid process to determine distance for tube insertion 3. Insert tube into Navi's and advance upward and backward until resistance is met, rotate catheter gently and advance into nasopharyngeal 4. Ask client to take sips of water if he or she is able while tube is advanced gently into stomach 5. Tape tube in place

10. The LVN is counting a client's respiratory rate. During a 30 second interval, the LVN counts 6 respirations and the client coughs three times. In repeating the count for a second time 30 second interval, the LVN counts 8 respirations. What respiratory rate should the LVN document?

16 BPM

34. A child is admitted to the ED for accidental ingestion of a poison. The LVN should know that inducing vomiting is recommended for which child?

16 month who drank 2 ounces of acetaminophen elixir Hepatotoxic

The LVN is caring for a client who has delusions of infidelity. Which situation would justify violating the clients right to confidentiality?

Confidentiality is waived if a client threatens the life of another person

3. The client is receiving 5% dextrose in 0.45 NS at 75 ml/hr. There is no available IV pump at this time. Using an IV administration set delivers 15 drops per ml , the nurse would need the tubing set to deliver_______ drops per minute in order to achieve the physician ordered rate. Enter numeric value only

19 15 gtt/min to deliver 1 ml 15 x 75 = 1125 drops/hr 1125/60 = 18.75 rounded to 19

49. A client has an oral intake during the previous 8 hrs of the following: 2 cups coffee, 240ml milk, 3/4 cup applesauce, 1 liter of water, 6 ounces fruit juice, and 3 ounces of pudding. How many milliliters will the LVN record as the total 8 hour oral intake? Round to the nearest whole number)

1900 ml

The LVN is reinforcing teaching to a client prescribed hydrochlorothiazide twice a day. Which instructions should be included in the reinforcement teaching?

Administered the second dose of the day before 6pm Notify their HCP if their heart rate is less than 60 or more than 100 bpm Carry a medical ID card in their wallet Weight daily at the same time of day, wearing the same type of clothing each time

4. A client transferred to the ICU after evacuation of a subdural hematoma. Which nursing intervention would reduce the clients risk of ICP?

Administering a stool softener as prescibed

The LVN is preparing to administer an IM dose of 450,000 units of penicillin G potassium (Buffered Penicillin G potassium for injection) The medication is available in a powdered form and the vial is labeled, "Mix with 3.8 ml diluent for concentration of 250,000 units/ml." The LVN should administer how many ml of medication?

1.8

The LVN is preparing to administer an IM dose of 450000 units of penicillin G potassium ( Buffered Penicillin G Potassium for injection) the medication is available in powdered form and the vial is labeled, "Mix with 3.8 ml diluent for concentration of 250000 units/ml. The LVN should administer how many ml of medication? Enter the numerical value only. If rounding is required, round to the nearest tenth

1.8 450000/250000= 1.8

17. The mother of a 6. Month old asks the LVN when her baby will get the first measles, mumps and rubella (MMR) vaccine. Based on the recommended childhood immunization schedule published by the CDC and prevention, which response is accurate?

12 - 15 months

23. The LVN is reviewing characteristics of the newborn and is sharing common growth and development milestones with new parents when they ask, when will the soft spot close? The LVN should respond that they can expect the infants fontanels to close during what age span?

12- 18 months

36. The LVN administered 15 units of NPH insulin subcut to a client before they consumed their breakfast at 0730. At what time is the client at an increased risk for hypoglycemia reaction?

1530- 1930 NPH intermediate acting insulin (8-12 hours)

28. What is the depth of the compression the LVN should do when performing the manual chest compression during CPR on an adult client?

2 inches to 2.4 inches (5cm-6cm)

73. A client is prescribed codeine USP 60 mg q 4hrs. The available medication is codeine USP 30 mg tablets. How many tablets should the LVN nurse administer?

2 tablets 60/30=2

8. While performing colostomy care, the LVN observes skin irritation around the stoma site. What action should the LVN take when reapplying the colostomy bag?

Ensure that the hydrocolloidal stomal wafer covers the peristomal skin

3. The LVN in the clinic receives a phone call from a mother of a 6 y/o with newly applied cast for a fracture of the femur. The mother reports that the child is in pain and crying and that the child's foot appears swollen and blue. Which nursing DX supports the LN initial intervention?

Altered peripheral tissue perfusion

48. The LVN working on an adult medical surgical unit would accept which of the following assignments under the supervision of the RN as appropriate to the LVN scope of practice?

An 81 y/o client with CHF and emphysema admitted 3 days ago

46. An elderly client DX with dementia was admitted from a long term facility to the hospital 2 days ago. The client's children express concern that their parents confusion has gotten worse since being admitted. How should the LVN respond.

Confusion in an older adult is expected with a relocation to new surroundings

An interdisciplinary treatment team meets to discuss a client DX with paranoid schizophrenia and cannabis abuse who is experiencing increased hallucinations and delusions. How should the team plan an effective treatment?

Consider each DX primary and provide simultaneous treatment

7. A cline with glaucoma has been prescribed pilocarpine ( Pilocar). The nurse explaining the use of the medication would state that it is useful because it works by

Constricting the pupil

The LVN is administering the dose of chlorpromazine via IM injection. Which method is ideal for administering the medication?

Ensure the client remain lying down for 30 minutes after injection

4. The LVN is administering medications to a client via NG tube. The 0900 medication include a sustained release spansule. Which action should the LVN take when administering the sustained release drug drug via NG tube?

Consult the HCP for a different drug form that can be crushed

The LVN is providing care to an adolescent with a DX of mononucleosis. What is the principle pathogen responsible for infectious mononucleosis?

Epstein Barr

27. The HCP prescribes clonazepam 1.25 mg. The medication is available in 0.50mg tablets. What should the LVN administer?

2.5 tablets 1.25/0.50= 2.5 tablets

A client has a prescription for one liter of 0.9% NS solution to infuse over 12 hours. The IV administration set delivers 15 gtt/ml. The LVN should set the drop rate at how many drops per minute? Enter numeric value only, round to the nearest whole number

21 12x60= 720minutes 1000x 15= 15000/720= 20.833 round to the nearest whole number 21

26. Following a vaginal delivery in a birthing suites, the LVN observers that a newborn has respirations that are 58 BPM an cyanotic hands and feet. What action should the LVN implement?

Continue observing infant Normal BPM 40-60

50. A mother calls the clinic and states that she does not know how many tsp of medication to give her child b/c the directions on the bottle read, "Give 15ml". How many tsps should the LVN instruct the mother to administer to her child? (Round to the nearest whole number)

3 tsps (5ml = 1 Tablespoon. 5x3= 15ml = 3 teaspoons)

38. Which intervention strategy should the nurse routinely include in the nursing care plan for a client with antisocial personality disorder?

Establish clear and enforceable limits

12. An elderly client is recovering from a hip fracture. The HCP has prescribed home health care nursing upon discharge. Which statement describes the primary goal for the client?

Establish self care and independence

37. An off duty LVN fins a female in a supermarket parking lot delivering an infant while her husband is screaming for someone to help his wife. Which is the highest priority?

Put the newborn to the breast Breastfeeding promotes contractions to stop bleeding

74. The HCP orders 1000ml of 0.45% lactated ringers to run over 8 hours. The drop factor is 15 gtt/ml. The nurse plans to adjust the flow rate to how many gtt/min? Round to the nearest whole number

31 gtt/min 1000ml x 15gtt = 15000/ hrs/min 8x60= 480min 15000/480min= 31.2 round to the nearest whole number 31

53. A client who is prescribed carbamazepine for the treatment of tonic clinic seizures asked why they are required to have weekly blood test. The LVN informs the client that the weekly blood test are necessary to monitor for which complication?

Decreased immune response

51. A client status post cholecystectomy three days is being prepared for discharge. Which client finding is the best indication to the LVN that postoperative nursing interventions have prevented respiratory complications?

Has a 95% pulse oximeter value on room air

A client on the unit is scheduled for weighing. The LVN asks the UAP to weigh the client. The UAP acknowledges and accepts the assignment. The LVN six hours later reviews the client record and notes an increased 4.2kg difference in weight from previous day. The LVN should be most concerned with which right of delegation?

Direction/communication

27. When performing sterile wound care in the acute care setting, the LVN obtains a bottle of NS from the bedside table that is labeled opened and is dated 48 hours before current date. What is the best action for the LVN to take?

Discard the NS and obtain a new and unopened bottle of NS

30. The nurse is collecting 24 hr urine specimen from the client. After collecting the first specimen, the nurse should

Discard the specimen, and then begin collecting

31. A patient is admitted with severe, crushing chest pain. The medical DX is possible MI. Which data would be MOST important to collect in the initial assessment?

Ask the patient if rest relieves the pain

38. When caring for a client on digoxin therapy, the LVN knows to be alert for digoxin toxicity. Which finding would predispose this client to developing digoxin toxicity?

Low serum potassium levels

21. The nurse is preparing to administer ampicillin 225mg to a pediatric client. The medication is mixed 250 mg in 5 ml. How many ml of medication would the nurse prepare to give 225 mg? Enter numeric value only

4.5 250 mg in 5. Ml = 50 250/50= 4.5

____________the LVN needs to administer 50mg of ranitidine (Zantac) as an intermittent IV infusion. The medication is diluted in 100ml 5% dextrose solution. The LVN plans to administer the infusion through and infusion pump over 15 minutes. The LVN should set the pump to infuse how many ml per hour?

400 100ml/15min= 100ml/.25 hour = 400ml/hr .24x100/.25=x=400

26. The client is receiving 5% dextrose and 0.45% sodium chloride IV and is complaining of pain at the IV site. The nurse monitors the site and notes erythema and edema. Recognizing these as signs of phlebitis, which of the following would be the appropriate nursing actions?

Discontinue the IV and apply a warm compress to the IV site

20. 24 hours after a full term newborn is admitted to the newborn nursery, the LVN observes a localized swelling on the right side of the head of the newborn. What is the most likely cause of the accumulation of blood between periosteum and skull, which which does not cross the suture line in a newborn?

A cephalhematoma, which is cause by forceps trauma

73. A client has been prescribed pregabalin. Which outcomes should the LVN anticipate a client to experience? Select all that apply

A decrease in joint pain resulting from osteoarthritis Improved ROM during PT

49. A physician has ordered a NG tube to be inserted for a client with full thickness burns to the legs. Which of the following actions by the nurse to confirm NG tube placement would be a priority before starting a continuous external feeding?

A have placement checked by x-ray

10. A female who thinks she could be pregnant calls her neighbor, a LVN to ask her when she should use a home pregnancy test to DX pregnancy. Which is the best response

A home pregnancy test can be used right after your first missed period

The LVN is reviewing the assessment of a client with a six-week history of persistent cough, rusty colored mucus, 10 lb weight loss, decreased appetite, and night sweats. Based on the history which nursing action should be done next?

A mask to be placed on the client and the client moved to a private room

2. The parents of a 1y/o who has recently DX with hypospadias, state that they plan to delay to corrective surgery to see if the child will outgrow the problem. What information is best for the LVN to provide to these parents?

Discuss the child's DX with the HCP for additional information and clarity

24. The LVN is evaluating the play behaviors of a 2 y/o child. Which behavior should the LVN expect the toddler to exhibit?

Displays possessiveness with toys (MINE!)

48. When initially monitoring a client after a fall, which information should theLVN communicate immediately to the HCP? Select all that apply

A. change in LOC E. Onset nausea and vomiting

56. A client prescribed ephedrine nasal drops 0.5% PRN complains of having difficulty falling asleep to the nurse. What action should the nurse take to minimize the clients insomnia?

Administer the dose a few hours before bed

26. The LVN prepares to administer eye drops and eye ointment to the client with a left eye infection. Which nursing intervention is the most effective for administering the medications?

Administer the eye ropes first and then the ointment

The LVN receives a prescription to administer 80mg of furosemide (Laxis) PO to a child who weights 44lbs. The recommended dose is 2-6 mg/kg. Which action should the LVN take?

Administer the medication as prescribed

52. A client sustained a burn injury greater than 25% of total body surface with majority of it lower extremities during a house fire. During the acute phase of care, which intervention is most important for the LVN to implement?

Administer 0.5 ml of tetanus toxoid IM Prevention of infection

47. The nurse is caring for a preoperative client who has DM. The clients fasting blood sugar is 256 mg/dl. What task should the nurse complete first?

Administer 6 units of Humalog insulin per sliding scale Regular insulin

72. A first day post op client vomits 30 minutes after receiving a dose of hydromorphine. What initial intervention is best for the LVN to implement?

Administer a PRN dose of ondansertron (zolfran) IV

4. The nurse should counsel the parents of a child with asthma that before performing postural drainage exercise, they should do which of the following

Administer her bronchodilator

26. The LVN is monitoring a client with alcohol dependency who is admitted for detox. The client complains of headache, the vitals are 149/96, pulse 104 bpm and temp 100.9F. What action should the LVN implement?

Administer lozaepam 2mg

1. A client is receiving chemotherapy for cancer and develops thrombocytopenia. What should the nurse in the clients plan of care because of the thrombocytopenia?

Administer no injections

Four clients are requesting pain medication and it is within their prescribed dosing time. All client s achieved pain relief after their last dose. Now the clients have reported their pain on a 1-10 pain scale. Which should be the first client the LVN administer pain medication?

After the first dose, pain was 1/10; now pain is 6/10

64. The LVN is reviewing high risk factors for T2D with a client. Which of the following characteristics are risk factors for the development of diabetes? Select all that apply

Age 40 and older African American Obesity Hispanic

17. A 7 y/o child is brought to the ED for acute asthma attack. He is wheezing, tachypneic, diaphoretic, and looks frightened. The nurse should prepare to administer

Albuterol ASAP

72. The LVN is reinforcing osteoporosis prevention education to a group of senior citizens. What life style choices will help decrease developing osteoporosis? Select all that apply

Alcohol in moderation and smoking cessation Regular weight bearing exercises Consumption of a diet rich in calcium and vitamin D

47. On admission, the client DX as a substance abuser is described as delusional. The LVN understands that this client is out of contact with reality and is experiencing which of the following symptoms? Select all that apply

Alcohol withdrawal Psychotic

45. A client received a prescription for cyclosporine ophthalmic emulsion for dry eyes asks the LVN if it is safe to continue using artificial tears. What information should the LVN provide?

Allow a 15 minute interval between the administration of cyclosporine and artificial tears

6. The nurse is caring for the client upon return to the nursing unit from the post anesthesia care unit (PACU) and notes the presence of a drain in the surgical wound. A family member observes the drain and asks why the tube was left in the wound. The nurse explains that drains

Allow drainage of excessive fluids such as blood, edema or pus from the surgical site

22. Before discharge, what information should the LVN give to parents regarding the newborn's umbilical cord care at home?

Allow the cord to air dry as much as possible

5. The LVN is administering a rectal suppository to a client. What action should be implemented to prevent discomfort during administration?

Allow the suppository to soften before insertion

16. Several days after hospitalization, a client is repeatedly washing the top of the same table. Which intervention should the LVN to implement first to help the client cope with anxiety related to this behavior?

Allow time for ritualistic behavior and then redirect the client to other activities

25. A client who become agitated an hour previously is now pacing the hallway and asking to leave the mental health unit. What action should the LVN take first?

Allow to continue pacing

A client seeks assistance at a crisis center. The client describes being extremely anxious and unable to sleep since helping with clean up duties at a school where a student fatally shot a teacher and some classmates. Which intervention is the priority when assisting the client?

Allow ventilation of feelings

21. A client scheduled for open heart surgery is prescribed a transfusion of 4 units of PRBC's. Which intervention is the best method to prevent a blood transfusion reaction?

An autologous transfusion (This is the clients own blood)

38. The LVN is caring for a client who has had a normal vaginal delivery. The firsts 4 hours after delivery the nurse palpates the uterine fundus and bladder every hour. What is the primary reason for implementing this nursing intervention?

An over distended bladder could inhibit uterine contractions an predispose to postpartum bleeding

16. The LVN caring for a laboring client encourages her to void at least every two hours and record each time the client empties her bladder. What is the rational for implementing this nursing intervention?

An overdistended bladder could be traumatized during labor and could prolong the process of labor

18. A client DX with diabetic neuropathy has a non healing ulcer on the lateral aspect of their right foot. Which question should the LVN ask to gather objective data for the development of a diabetic foot care teaching plan?

Ask to look at the pair of shoes they wear

29. Which OTC medication should the LVN recommend that breastfeeding mother avoid?

Aspirin Due to Reyes disease

4. A client DX with a skull hematoma and fractured (L) clavicle status post a six foot fall from a ladder is admitted to the unit. Which sign should the LVN report immediately?

Answers questions but is confused

18. In teaching the client about factors that can decrease the effectiveness of oral contraceptives, which of the following should be included by the nurse

Antibiotic use

The LVN is reinforcing teaching to a client DX with psoriasis. What should the client be instructed to avoid?

Antimalarial medication

13. Certain that her stomach pain is a symptom of cancer, a female client with somatization disorder exhibits pressure, rapid speech, elevated pulse and blood pressure, palpitations, and preoccupation with her pain, despite negative results from a gastroscopy . The nurse formulates which of the following as the priority nursing DX?

Anxiety

1. The nurse has applied elbow splints on a confused client to prevent the client from receiving the IV line. Which of the following interventions is required?

Assess and document client condition at least q hour

25. Which intervention is most important for a LVN to implement for a client who is experiencing urinary retention?

Assess for bladder distention

39. A 2 y/o child who is hospitalized with an acute upper respiratory infection (URI) is crying uncontrollably because her mother went to the cafeteria for lunch. Which action should the LVN implement?

Distract the child with a favorite toy

32. A LVN is getting ready to administer digoxin to a client. Which assessment finding would require the nurse to hold the medication?

Apical pulse rate of 50 bpm

40. The client status post 48 hour femoral rod placement surgery, suddenly complains of chest pain and becomes SOB, pale, and diaphoretic. The LVN immediately assess their vital signs and obtains 100/80 b/p, 110 PR, 36 bpm RR. What nursing action should the LVN to do next?

Apply oxygen 2 l/per nasal cannula

The LVN is administering beta blocker eye drops for a client's glaucoma. What is the most important step to prevent the client from experiencing syncope or a fall injury?

Apply pressure to the nasolacrimal duct after administration

6. A 5 y/o tells the LVN that she needs a band aid when she has an injection. Which action is best for the LVN to take?

Apply the band aid over the injection site

38. Which action should the LVN implement first when obtaining the tympanic temperature of 2 y/o child?

Apply the probe cover to the electronic

33. A client is DX with HEP B virus infection. The LVN who has been vaccinated with the HEP B series is assigned the client. What precautions should the LVN implement when providing caring for this client?

Appropriate PPE should be worn if possibility of increased risk of bodily fluid exposure

22. An older client is prescribed gentamicin sulfate. Which question should the LVN ask an older client beginning treatment?

Are you hard of hearing

34. A new mother is breastfeeding her infant asks the nurse, "what kind of stools will my baby have, and how many will there be during the next month?" Which of the following would be the best response by the nurse? Your baby should have

As many as 6-10 small, loose, yellow stools per day

71. A client who is being discharged to home asks the LN for a dose of hydrocodone before leaving the hospital. How should the LVN respond to this client's request?

Ask him to describe the location and severity of the pain and rate it 0/10

45. While talking with a female client DX with schizophrenia, the nurse notices the client look away from the nurse and stare at thee wall while making facial grimaces. What is the MOST appropriate intervention by the nurse?

Ask the client if she sees somethings on the wall

12. A client comes to the clinic and reports the presence of a painful lesion in the genital area; they described it as a blister 2 days earlier that is now crusty. Which intervention should the LVN implement first?

Ask the client if they had unprotected sex

14. The LVN is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later, the client reports that the insomnia continues despite following the same routine every night. What action should the LVN take first?

Ask the client to describe the current routine practiced by the client.

1. The HCP informed a client DX with stage 4 liver cancer that the cancer has spread to their spine. The client states to the LVN " I have a cancer, but it is not malignant." What is the best initial nursing action?

Ask the client to explain his understanding of the term malignant

50. When a female client preparing for surgery suddenly burst into tears, the nurse should take which of the following actions?

Ask the client to share what she is feeling

40. A child with acute appendicitis who is scheduled for surgery in 3 hours is complaining of abdominal pain. Which intervention should the LVN implement?

Assist the child into a position of comfort

40. When a client who delivered an 8lbs 12o infant 6 hours earlier is ambulating to the bathroom for the second time since delivery, the LVN observes blood running down her leg. What action should the LVN take?

Assist the client back to the bed and check her fundus

20. The spouse of a client who has been physically abused refuses to leave the clients room during the admission interview. Which action should the LVN implement?

Assist the client to walk to a treatment room on the unit

66. Client DX with COPD complains to the LVN of extreme fatigue after coughing. Which self care measures can help minimize the clients dyspnea? Select all that apply

Assume a sitting position with shoulders relaxed and knees flexed Support forearms with a pillow and place both feet on the floor Slightly drop head bend forward, and slowly exhale with pursed lips Resume sitting up straight, using diaphragmatic breathing to inhale slowly and deeply

16. When teaching a female client to perform breast self exam (BSE), the nurse should instruct her to perform the exam

At the same time each month Completion of menstrual cycle

62. Benztropine is prescribed for a client with Parkinson's disease. After a few days of therapy, the client complains of constipation and abdominal distention. What response by the LVN would be most appropriate?

Auscultate for bowel sounds and ask the client when they had their last bowel movement

10. A client status post-AV (arteriovenous) fistula placement in the right forearm is transferred from the PACU to the unit. Which nursing measure is essential in promoting safe, effective care for the client?

Avoid B/P's or needles in the right arm

34. The LVN is reinforcing teaching to a new mother about diet and breastfeeding. Which instruction is most important to include?

Avoid alcohol because it is excreted in the breast milk

5. A client has had cataract surgery. What is the most important post surgery instruction that the LVN should implement?

Avoid benign over Rational- avoid heavy lifting, straining and bending over to prevent intraocular pressure

44. A client with hip replacement is concerned about dislocation of the prosthesis. What can the nurse say to reassure the client?

Avoiding activities that cause adduction of the hip to prevent dislocation.

27. The LVN gives written discharge instructions to an elderly client who has undergone cataract surgery on the right eye. Which discharge instructions should the LVN reinforce?

Avoiding sleeping on right side

75. The LVN prepares to administer ophthalmic drops to a client before cataract surgery. List the steps in order that should be implemented for the first step to the last.

B wash hands and apply clean gloves C place the dominant hand on the clients forehead A drop prescribed number of drops into the conjunctival sac D ask the client to close the eye gently

10. A female client who started taking an oral sulfonamide for a UTI the previous day reports to the nurse that the medication is causing slight anorexia. She also states that she continues to experience urinary frequency, so she takes the medication with a glass of cranberry juice and with a snack. What information should the LVN provide?

Continue to drink the cranberry juice, but take medicine on an empty stomach with a full glass of water

The LVN performs a focused assessment on a clients bowel sounds. The LVN listens to all four quadrants of the abdomen over one full minute and does not detect any audible sounds. The LVN should do which nursing action next?

Continue to listen for the presence of bowel sounds

The LVN is assessing a client who is in her 2nd trimester. The LVN notes the client's heart rate is 15bpm higher than her prepregnancy rate. Which action should the LVN take next?

Continue with the focused assessment

21. A clinet has been prescribed an angiotensin 2 receptor antagonist losartan. Which change in data indicates to the LVN that the desired effect of this medication has been achieved?

B/P reduced from 160/90 to 130/80 mmHg

Older client reports parsthesia in the feet and hands, weight loss, and fatigue. The LVN performed a focused assessment and the findings revealed a smooth beefy red tongue and poor balance. Which type of anemia should the LVN suspect?

B12 deficiency anemia

19. The LVN is caring for a client who has been DX with early Alzheimer's disease. With which activity does the LVN expect the client to experience the most difficulty?

Balancing a checkbook Rational- early stages of Alzheimer's disease, the client has difficulty with complex task, such as balancing a checkbook

The LVN observes a psychiatric clinical nurse specialist use cognitive behavioral therapy (CBT) techniques as she works with bulimic client. Which statement by the nurse is an example of the application of CBT principles?

Being thin does not seem to solve your problems; you are thin now and still unhappy

15. A client is admitted for surgery. During the preop exam, the nurse learns the client is taking warfarin sodium ( Coumadin). When planning postoperative care for this client, the nurse would include monitoring for which of the following?

Bleeding or oozing at the surgical wound

The LVN is providing care to a client with acute pancreatitis. Which prescription should the LVN anticipate to be included in the clients plan of care?

Blood glucose levels

44. The HCP prescribes carbamazepine for a child whose tonic-clonic seizures have been poorly controlled. The nurse informs the mother that the child must have blood test every week. The mother asks why so many blood test are necessary. What complication is assessed through frequent lab test that the nurse should explain to this mother?

Bone marrow suppression

16. A child is admitted to the hospital for conformation of a DX of acute lymphoblastic leukemia. When performing a nursing assessment, which symptoms that are commonly manifested by the condition should the LVN observe in the child?

Bone pain Pallor- pale skin color

At what minimal ages should a referral be made to a healthcare provider for delay in sexual maturity/puberty of a male/or female client?

Boys by the age of 14; girls by the age of 13 Y/O

1. The LVN calls for help and gives two breaths to a newborn who is not breathing. Which are would the LVN check for a pulse?

Brachial pulse

45. A 70 y/o client status post hip replacement is transferred to a rehab facility. Which scale should the LVN identity as the best tool to predict the clients risk for developing skin breakdown?

Braden scale Sensory perception, moisture,activity, mobility, nutrition and friction/shear

32. A breastfeeding postpartum client is DX with mastitis, and antibiotic therapy is prescribed. What instruction should the LVN reinforce to the client?

Breastfeeding the infant, ensuring both breast are completely emptied

25. A mother phones the clinic because her 6 y/o child has been taking prescribed antibiotics for 7 of the previous 10 days and continues to cough. She also reports that the cough is worsening and nonproductive. What information should the LVN provide to their mother?

Bring the child to the clinic today for an examination related to the cough

20. A client DX with seizures is prescribed phenytoin. Which medication instruction should the LVN reinforce to this client?

Brush and floss teeth daily

11. A client receiving chemotherapy is experiencing mild stomatitis. Based on an understanding of this complication, the nurse will tech the client which of the following measures?

Brush teeth with a soft toothbrush before and after meals

42. The clients prenatal education includes danger signs to report. Which of the following, if reported would indicate that the client understood the teaching

Dizziness and blurred vision

27. A client prescribed chemotherapy asked the LVN, "why is so much of my hair falling out each day?" Which response by the LVN best explains the reason for alopecia?

Chemo affects the cells of the body that grow rapidly, both normal and malignant

14. A full term infant is admitted to the newborn nursery. During the initial PO feeding, the LVN observes the infant for possible tracheal esophageal atresia. Which symptoms are likely to be exhibited during the feeding if this condition is present?

Choking Coughing Cyanosis

42. The client receives a prescription for a 5 mg dose of the drug. The oral preparation of the drug is available as 3 mg/capsule. Which intervention should the LVN implement?

Call the HCP about the prescribed dose

11. A short arm cast is applied to a child with a fractured (R) ulna. The LVN is preparing the parents with home instructions and should reinforce that the parents follow which discharge instructions?

Call the HCP immediately if the nail beds appear blue or empty

23. The LVN delivers a food tray to an elderly Jewish person who has requested a kosher diet. The LVN checks the tray and notes that it contains bacon, eggs, toast, oatmeal, and coffee. Which action should the LVN take?

Call the dietary department and request a new tray

38. The daughter of an older adult who is confused asked the LVN for guidance regarding the use of alternative dietary supplements to treat Alzheimer's. Which information should the LVN provide?

Carefully reviewing information regarding research findings

15. A HCP prescribed an antibiotic for a client. Which of the medications listed should be used with caution when given to a client with a penicillin allergy?

Cephalosporins

The LVN is obtaining information from an older client who reports an allergy to penicillin. Which other medication may have cross reactivity?

Cephalosporins (cephalexin) keflex

The staff LVN is frustrated about the lack of necessary equipment on the unit. The LVN sends an email to the chief medical officer of the hospital regarding their frustration, noting that client care is being compromised. The nurse manager is called to administration suite to discuss the issue, and the staff LVN is verbally warned. Which procedural issue caused the verbal warning?

Chain of command

35. A client DX with bacterial meningitis is admitted to the unit and is prescribed neuro checks every 2 hours. Which manifestation would the LVN monitor for that would provide the first indication of altered neurological function?

Change in LOC

34. An older client who attends a adult day care program and who is wheelchair-mobile has redness in the sacral area. Which instruction is most important at for the LVN to provide?

Change positions q 2 hrs

24. The LVN is assigned a client DX with a hemothorax who had a chest tube inserted 36 hours ago; upon entering the room, the LVN observes the client resting comfortably in the semi flower position; respirations appear even and unlabored; the water in the water seal chamber is bubbling; and there is serous drainage noted in the collection chamber. What is the best initial action for the LVN to take?

Change the client to high flowers position

25. A newborn infant is breathing satisfactorily but appears dusky. Which action should the LVN take first?

Check oxygen saturation level

39. The nursing is passing medication in the day room of a long term facility. Which of the following is the bet technique for the nurse to use to prevent medication error when passing medications?

Check the ID bracelet of each client

35. When assisting an older adult client to take a tub bath, which nursing action is most important?

Check the bath water temperature

36. The nurse is attempting to obtain B/P measurements in a 6 y/o client. The client is in a good health, has had been cooperative, and appears to be calm. The child's B/P is 115/75. What should the nurse do?

Check the cuff size and consider changing to a larger cuff

37. A client status post hip replacement 24 hours ago has been prescribed enoxaparin 30mg IVP bid x 4 doses. Which intervention is most important for the LVN to implement?

Clarify the prescription with the right now and HCP

11. The clientDX with a UTI has been prescribed phenazopyridine. Which data would indicate to the LVN that the therapeutic outcome has been achieved?

Client denies pain when voiding

42. Which client requires the most immediate intervention by the LVN?

Client experiencing sudden onset of confusion and disorientation

34. A client has been taking levodopa (Larodopa) for tremors, shuffling gait, and rigidity. To evaluate the effectiveness of the medication, the nurse would document which of the following in the chart?

Client is able to be more ambulatory

21. Thee LVN is caring for an older client DX with Alzheimer's dementia. Which behavior by the client should the LVN be the most concerned about?

Climbing out of bed Rational- risk for falls

Jackson-Pratt wound drainage device

Closed suction medical device that is commonly used as a post operative drain for collecting bodily fluid from surgical sites

18. The client complains of nausea and vomiting about one hour after taking the morning dose of an oral anti diabetic agent, Glyburide. What is the priority nursing intervention?

Closely monitor the blood glucose level and watch for signs of hypoglycemia Rational- when a client who has taken an oral anti diabetic agent vomits, the LVN should omit or the blood glucose level and watch for signs of hypoglycemia

27. The LN is assessing an 8 month old who has a medical DX of tetralogy of Fallot. The child demonstrates cyanosis with crying and exertion. Which other symptoms is this infant most likely to exhibit?

Clubbing fingers and toes

48. An elderly client who is recently transferred from the critical care unit suddenly begins hallucinating, and becomes disorientated and fearful. The LVN should expect to implement which intervention based on the nursing DX of confusion related to ICU psychosis? Select all that apply

Cluster are to maximum rest periods during the day Encourage visitation by friends and family Reorient client to change between day and night

10. The client with fibrocystic breast disease is most likely to report a diet high in which of the following?

Coffee and cola

7. A HIV unit nursing team, composed of the RN case manager, staff RNs, and LVN, is meeting to discuss a client who has developed anorexia related to HIV medications. The client has lost 15lbs in the pervious 2 months. Which action should the team implement to continue the nursing process?

Collaborate with the client to set goals

12. A client at 30 weeks gestation is complaining of pressure over the pubic area. At the client's admission to the antepartum unit for observation, vaginal exam shows that her cervix is closed, thick and high. The fetal monitor reveals irregular contractions and underlying uterine irritability. Which intervention should the LVN implement first?

Collect a specimen for urine analysis

34. A 2 y/o child had tympanostomy ventilating tubes inserted into both tympanic membranes (TMs) 1 week earlier. During postoperative clinic visit, the LVN notes that the child has purulent discharge from the right ear, and the mother explains that the toddler has a cold for 3 days. What action should the LVN plan to implement?

Collect a specimen of the otorrhea for culture Purulent discharge infection

The LVN is performing a focused assessment with an older client to determine the clients ability to perform ADL's. Which behavior should the LVN identify as an ADL when completed by the client?

Combing hair

9. A client at 38 weeks gestation calls the antepartal clinic stating she just experienced a small amount of bright red vaginal bleeding that has subsided. She denies uterine contractions or abdominal pain. What information should the LVN provide?

Come to the clinic today to see HCP

22. The nurse on a cardiac unit is caring for a client admitted with an acute exacerbation of heart failure. The nurse concludes that the client is developing pulmonary edema after observing which change in the client?

Cough with pink frothy sputum Right sided heart failure

A client with stage 3 Alzheimer's is admitted to a behavioral health hospital. Due to progression of the disease, the client is experiencing an increase in amnesia and agnosia, and has declined to the point of not recognizing familiar objects and people. Which action should the LVN do to help reduce the client's fear and anxiety and to help the client adjust to the new setting?

Cover mirrors and pictures if they are up sitting the client

20. Which instruction should the LVN provide to a client whose vision is being tested with a Snellen chart?

Cover one eye while reading the chart with the other eye

28. The nurse enters the room of a client who has a chest tube attached to a water seal drainage system and notices the chest tube is dislodged from the chest. The most appropriate nursing intervention is to

Cover the insertion site with petroleum gauze Then notify physician

13. The LVN reinforces the instructions to the client after hip replacement. Which action indicates the need for further education?

Crossing the feet while lying in bed

41. Which intervention should the LVN implement when a child cannot swallow prescribed tablets?

Crush tablets to aa fine powder and mix with a small amount of soft food

13. The LVN is caring for a child who had cleft lip repair. What is the most important reason to minimize this child's crying during the postoperative recovery period?

Crying stresses the suture line

49. A client DX with a fracture of the (L) radius has a plaster cast applied. Which instructions should the LVN give the client to dry the cast over the next 24 hours?

Do not cover and keep the cast surfaces exposed to circulating air

39. A client DX with angina has been prescribed nitrate isosorbide dinitrate. Which instruction should the LVN reinforce in this clients teaching?

Do not get up quickly. Always rise slowly

43. Clients with COPD are usually in low levels of oxygen via nasal cannula. What problem would occur if these clients receive too high an oxygen concentration?

Decrease in rate and depth of respirations

What are the physiological effects of high levels of cortisol released in response to prolonged exposure to stress?

Decrease in the body's immune systems response Development of gastric ulcers an irritable bowel syndrome Enlargement of the waist due to increase abdominal fat

45. The nurse is preparing a child for transport to the operating room for an Emergency appendectomy. The anesthesiologist prescribes atropine sulfate IM STAT. What is the primary purpose for administering this drug to the child at this time?

Decrease oral secretions

54. A client DX with viral influenza is prescribed Vit C 1000 mg PO daily and acetaminophen 650 mg PO q 4hrs PRN. The client complains to the LVN of abdominal cramping and increased episodes of diarrhea. Which prescription change should the nurse anticipate?

Decrease the dose of Vit C Adverse effect of vitamin c causes diarrhea, and abdominal cramping

20. The client is recently DX with Parkinson's disease an is to begin medication therapy. What is the purpose of the client's medication therapy?

Decrease tremors

16. The client's plan of care includes a nursing diagnosis of "altered sleep patterns related to nocturia. " which client information is important for the LVN to provide?

Decrease your intake of fluids after the evening meal

The LVN is assisting the nurse who is performing an assessment on a client who is newly admitted with diabetic ketoacidosis (DKA) while collecting the clients vital signs, the LVN anticipates which abnormal finding?

Decreased blood pressure

67. Which assessment finding indicates that expected outcome of administering donepezil to a client with Alzheimer's disease has been accomplished?

Decreased confusion and improved mood

9. An inpatient client on the psychiatric unit is being treated for paranoid schizophrenia. As the nurse approaches the client says, " you're with the FBI, I can tell by the way you are walking. The nurse should recognize this as a

Delusion

40. A male client comes to day treatment surrounded by an intense odor of alcohol. The client staggers when walking but insists that he has not consumed any alcohol. The nurse concludes that this behavior constitutes which of the following?

Denial

46. Which of the following clients should the nurse plan to see first after receiving inter shift report?

Depressed client suddenly feeling much better

14. A client is admitted to the psychiatric inpatient unit with DX of major depression after retirement from work. The initial nursing care plan includes the goal that the client will identify psychosocial stressors that may have a negative effect of the clients depression and begins to modify them. What is the LVN expectation of the client related to this goal?

Depression should dissipate once the client adjust to life changes and developmental tasks

5. A client who is tearful and experiencing suicidal thoughts associated with memories of childhood abuse is admitted to the mental health unit. The client reports having nightmares, difficulty sleeping and inability to cope at work. Which nursing DX is a priority for the LVN when implementing the plan of care?

Depression with suicidal thoughts

2. In evaluating a clients response to an antidepressant medication, which statement should the LVN expect to hear from a client who has been taking the medication for 10 days?

Describes only awakening occasionally during the night

24. A female client tells the nurse "sometimes I wish I could go to sleep and not wake up" the cleint reports suicidal thoughts when questioned by the LVN. Which action is most important for the LVN to take?

Determine if the client has a plan to committing suicide

43. The HCP prescribes the anticonvulsant carbamazepine (Tegretol) for an adolescent client with a seizure disorder. The nurse should instruct the client to notify the HCP if which condition occurs?

Develops a sore throat Flu like symptoms such as pallor Fatigue Fever Indications of such dyscrasias

52. An adolescent client with seizures disorder is prescribed the anticonvulsant medication carbamazepine. The nurse should notify the HCP if the client develops which condition?

Develops a sore throat Flu like symptoms, pallor, fatigue, sore throat, fever

13. A client whose seizure disorder has been managed with phenytoin is admitted to the ED with status epilepticus. Which drug should the LVN anticipate to be prescribed for administration to treat the seizures?

Diazepam Treatment of epilepticus

47. An elderly client with a history of cardiac disease is admitted to the hospital. Since admission, the client has been confused and complaining about muscle cramps and vomited twice. The client's vital signs are B/P 130/70, P 47 and RR 18. Which medication in the client's history should the LVN be most concerned?

Digitalis accumulation and Toxicity of cardiac glycosides can occur

30. An older client is admitted to the hospital after experiencing confusion, nausea, vomiting, and headache for several days. The clients pulse rate is 43 BPM. The LVN is most concerned about the client's history related to what medication?

Digoxin

21. The LVN is caring for a toddler who is admitted for cleft palate repair. Which type of restraint should the LVN prepare to apply in the postoperative period?

Elbow To prevent bending of arms

5. A nurses client is deteriorating. The clients vitals are B/P 95/58, heart rate 116 and respirations irregular at 28 bpm. What action should the nurse take first?

Elevate the HOB to facilitate breathing and comfort

40. While morning care is being provided, a client becomes restless, agitated, and confused. The clients heart rate is elevated, and respiratory rate is 24BPM. Which additional finding should the LVN identify as an early sign of hypoxia?

Elevated B/P

5. To minimize separation anxiety in a hospitalized 2 y/o, which nursing intervention is best for the LVN to implement?

Encourage parents to room in

48. A child has been DX with a brain tumor, but surgery cannot be scheduled for several days. The mother asks what she can do to ease her child's headaches. The LVN suggest that the mother

Encourage the child to sleep in a semi flowers possition

38. The LVN obtains a lying and standing B/P measurements for a client who complains of dizziness upon standing up from the computer at work. The LVN determines that systolic pressure decreases 24 mm Hg when standing. What intervention is most important for the LVN to implement?

Encourage the client to flex both feet before rising slowly

3. A nursing DX of ineffective family processes related to hospitalization of child with a potentially fatal condition is formulated for the family of a child who sustained a brain injury during an automobile accident. Which of the following interventions would the highest priority for the LVN?

Encourage the family to ask questions and express feelings

18. The total bilirubin level of a 36 hr breastfeeding newborn is 14 mg/dl. Based on this finding, which intervention should the LVN implement?

Encourage the mother to breastfeed frequently Normal levels of total bilirubin level 6-12 mg/dl

22. The LVN is reviewing signs and symptoms of CHF with parents of a 2 y/o child with a congenital heart defect. Which behaviors is most important for the parents to report to HCP?

Exhibits a sudden and unexpected weight gain

10. The LVN is caring for a child with a DX of acquired aplastic anemia. What should the LVN expect in the child's health history that is common cause of this type of anemia?

Exposure to certain drugs Chloramphenicol, sulfonamides, phenylbutazone, insecticides, such as DDT and chemicals in particular benzene

7. A client in active labor begins to experience cramps in her leg. Wha intervention should the LVN implement?

Extend the leg and doriflex the foot

41. The nurse is caring for a client DX with bipolar disorder who is acting aggressively toward others. Which activity should the nurse consider for the client?

Finger painting

32. An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy. Stool cultures show the presence of c-diff. What information is most important for the LVN to tell the UAP about caring for this client.

Follow isolation precautions while caring for this client

41. A client DX with prostate cancer is prescribed radioactive seed implantation (brachytherapy) what is the most important nursing action for the LVN to do?

Follow radiation exposure precautions

44. The LVN reinforces information with a client about portion control and diet management. Which portion description indicates that the client understands the instructions?

Four small cookies are about the size of four poker chips

8. The LVN working at an assisted living facility is visiting with a client whose spouse died 8 months ago. Which behavior by the client suggest ineffective coping with the spouce's death?

Frequently neglects to shower and shave

29. The LVN is observing a new UAP performing indwelling catheter care for a female client who is incontinent of feces. What action should the LVN suggest the UAP to change?

Frequently rinse the washcloth used to clean the perineum

63. A client DX with DM complains of vomiting and feeling confused to the LVN. Which of the signs of diabetic ketoacidosis (DKA) select all that apply

Fruity breath odor Rapid, weak pulse Extreme thirst Urinary frequency Sunken appearing eyeballs

8. The nurse is assisting with teaching a group of adults about health screenings for cancer. The nurse would include in the discussion which of the following points? Select all that apply

Genetic screening is helpful in ID of cancer risks Men need to perform breast and testicle exams monthly

The LVN is providing care to a stable client DX with dementia and epilepsy. The client's spouse reports that they have started a new herbal regimen. The LVN should reinforce teaching to discourage the use of which OTC supplement?

Ginkgo Bilbao (thins blood)

34. A client has been admitted to the hospital with chest pain. The clients symptoms has not been relieved after one dose of nitroglycerin (NTG sublingually. The nurse monitors the vital signs and notices they are stable. Which of the following

Give another dose of nitroglycerine

18. The LVN is caring for a client DX with bipolar disorder who hypomanic. Which interventions should the LVN implement?

Give short simple direct explanations to the cleint

35. A client prescribed glipizide asked why they had to take their insulin orally. How should the LVN respond?

Glipizide is not an oral from of insulin and can be used only when some beta cell function is present Glipizide enhances pancreatic production of insulin

17. A new father asks the LVN why ointment is instilled into the eyes of his newborn infant. Which infection should the LVN identify when describing the purpose of this treatment?

Gonorrhea

6. A client DX with chronic schizophrenia was discharged from a mental health unit 6 weeks earlier and returns to the clinic for a follow up visit. The LVN recognizes which behavior as an indication that the client will maintain independent community living? The client

Has taken prescribed medications since discharge

25. A pediatric client has severe injuries to the abdomen. The nurse should suspect child abuse if the parents

Have delayed seeking treatment for the child's injuries

30. Clients receiving disulfiram for the for the treatment of alcoholism should be cautioned about the importance of avoiding alcohol, particularly during concurrent treatment with cephalosporin antibiotics, because an Antabuse reaction may be initiated. Which symptom would indicate that the client is experiencing a reaction to disulfiram?

Headache Vomiting Flushing

The LVN is participating in a committee that is evaluating sentinel events. Which situation should the committee review as a sentinel event?

Hemolytic transfusion reaction involving major blood group incompatibilities

4. The HCP has prescribed a 74 y/o client to be vaccinated with the flu vaccine prior to discharge. Which client condition will make thePN not to vaccinate the client and consult with the charge nurse?

History of an allergy to eggs

43. An older client who has a history of a hip fracture was admitted to the hospital for CHF. The client is taking codeine-acetaminophen as needed for pain. Which risk factor puts this client at greatest risk?

History of falls

2. A client is scheduled for an EEG early in the morning. The nurse working the night shift prior to the procedure would write a note to do which of the following per protocol in the early morning on the day of the test?

Hold the daily dose of anticonvulsant

44. A client DX with essential hypertension is prescribed phenylephrine for nasal congestion as needed q 4 hours. The client is complaining about nasal congestion. Which nursing action should the LVN do next?

Hold the medication and consult the charge nurse Causes hypertension

55. A client DX with a seizure disorder is prescribed phenobarbital. While attempting to administer the medication to the client, the LVN has difficulty trying to arouse the sleepy client. What nursing action should the LVN implement?

Hold the medication and notify HCP

36. A client who resides in a long term care facility has a seizure disorder that has been managed with phenobarbital for several years. Lately, the client has become more difficult to arouse. What intervention should the LVN implement?

Hold the medication and notify the HCP

32. A new mother calls the clinic 4 days after delivery. She is breastfeeding and is concerned that her baby is not getting enough milk. What is the most important question for the nurse to ask this mother?

How many wet diapers has your baby had in the last 24 hours

12. The nurse is caring for a client with T1DM. In developing a teaching plan, which of the following S/S of hypoglycemia should be included?

Hunger, shakiness, pale cool skin, and irritability

28. The LVN is assessing a client 2 days status/posthip replacement surgery. In assessing the client vital signs, which findings requires the most immediate action of the LVN?

Hyperthermia rational- hyperthermia, an elevated body temperature, requires the most immediate action to determine cause of fever an contact HCP

28. The LVN is assigned a client on digoxin therapy. Which finding is likely to predispose this client to developing digoxin toxicity?

Hypokalemia

42. A 59 y/o client is prescribed furosemide 40 mg twice a day for the management of heart failure. The LVN should monitor the client for the development of which complication?

Hypokalemia Low potassium

65. A 78y/o client prescribed furosemide 40mg PO twice daily is demonstrating EKG changes. Which condition should the LVN suspect is causing these changes?

Hypokalemia Low potassium

40. An older client DX with CHF is taking furosemide 40 mg twice daily. The LVN plans to monitor this client for development of which complication?

Hyponatremia Low sodium levels

64. A client who is taking hydrochlorothiazide is admitted to the hospital and is experiencing muscle weakness and cramping. Which condition should the LVN suspect is causing these changes?

Hyponatremia Low sodium

20. A client has just received a Holter cardiac monitor to wear for the next 24 hrs. The nurse determines that the client understands its use when the client makes which of the following statements?

I can continue with my usual activity and exercise pattern while wearing the monitor.

43. The nurse is working in Athens newborn nursery. The charge nurse asks the LVN to complete the nursing assessment and discharge teaching for the newborn. What would be the LVN best response?

I cannot perform discharge teaching or the nursing assessment because it is out of my scope of prectice

44. A client asks about a new DX test with which the nurse is unfamiliar. What i the best response

I don't know much about that procedure, but I will find out and bring you information about it.

43. A client has OCD. Which of the following statements made by the client to the nurse would be the BEST indicator of improvement?

I have more control over my thoughts and behaviors

2. A LVN reinforced client teaching regarding the transmission of the HIV virus. Which statement by the client demonstrates an understanding of the reinforced teaching?

I may still contract HIV even though I am 62 y/o

28. The nurse concludes that a client has an understanding of the side effects of furosemide (Lasix) and its relationship to potassium levels when the client states

I should call the DR. If I feel myself becoming dizzy when I stand up

The LVN is reinforcing teaching about dietary nutrition to a client DX with T2DM. The LVN identifies which statement by the client demonstrates an understanding about the teaching?

I should focus on eating plant based food with occasional fish and poultry

2. Phenytoin is prescribed for a client who has a seizure disorder. Which statement by the client needs to be clarified by the practical nurse?

I should take the medication with antacids if gastric upset occurs

16. Which of the following statement made by the client with a migraine headache would indicate to the nurse that she understands client teaching regarding migraine medication?

I will be keeping a GI ary of my headaches to see if there is a pattern

As the LVN is assisting in the care to a client who is 38 weeks gestation DX with premature rupture of membranes. The LVN identifies the client understands her plan of care treatment, by the client saying which statement?

I will be monitored closely for signs of infection

48. A client is prescribed phenobarbital 100mg daily for the treatment of seizures. Which statement made by the client indicates an accurate understanding of the medication phenobarbital?

I will take my medicine at 10 pm before retiring to bed

1. The H2 receptor blocker famotidine is prescribed for a client for GERD. Which client statement indicates to the LVN that the teaching was effective regarding concurrent use of these medications?

I will take the famotidine twice a day

20. A client status post closed-appendectomy is prescribed to begin ambulation the nest day. The next day when the LVN goes to assist the client with ambulation, the client yells they are watching TV and they don't feel like getting out of bed. Which response should the LVN provide?

I'll be back in 30 minute to help you get out of bed and walk around the room

What are the legal implication's of federally initiated healthcare acts on LVN practice?

Ignorance of the health acts is not permissible Encourages nurses to keep up with current standards Guides and defines legal boundaries of nursing practice

40. When the nurse begins to assist an elderly client DX with dementia out of bed, the client becomes angry and yells at the LVN "get out of here" I'll get up when I'm ready" which response should the LVN provide?

Ill be back in 30 min to help you get out of bed and walk around the room

33. A client receiving the antibiotic vancomycin is prescribed to have a peak and trough level done with the next dose. What time should the LVN obtain the blood specimen for the trough level?

Immediately before the next antibiotic dose is given

31. A primigravida is NPO 24 hrs post delivery by c-section, in using a patient controlled analgesic (PCA) pump for pain control, complains of nausea and bloating, has hypoactive bowel sounds and states she is too weak to breastfeeding her infant. Which nursing DX has the highest priority?

Impaired bowel motility related to pain medication and immobility

13. A client is admitted to a hospital with the DX of schizophrenia. Which findings should the LVN recognize as the most characteristics of the mental status of a client DX with schizophrenia?

Incongruent affect Flat effect

29. An elderly client DX with Alzheimer's disease has been receiving donepezil for the past 6 weeks. Which of the following changes would indicate that the medication has been effective?

Increase ability to solve simple problems

17. A new breastfeeding client is having difficulty with sore nipples. The nurse assesses the client for which of the following since it is the most probable cause of this problem?

Infant is not properly attached to the nipple, poorly positioned

13. While monitoring a clients IV the nurse notes that the area is swollen, cool, pale, and causes the client discomfort. The nurse suspects which of the following problems

Infiltration Blanching, coolness of skin, edema at site

25. The LVN is reinforcing colostomy care teaching to a client who is three days following placement of their colostomy. The client asked the LVN why is it necessary to measure the colostomy's stoma each time when changing into a new alliance/wafer. What is the best response by the LVN?

Inform the client that the stoma will become smaller when the initial swelling diminishes

The LVN reports to the nurse a client indicates interest in completing a living will, specifically noting the possibility of do not resuscitate (DNR) desires. Before the nurse can provide the facility's living will documents or further information, the client experiences cardiac arrest. The LVN identifies which of the following demonstrates the most ethical response by the nurse?

Initiate the cardiac arrest resuscitation and inform the HCP the client's conversation, and notify the family

23. The LVN is assessing a child with asthma for retractions during respirations. When should the LVN recognize the absence or presence of intercostal retractions?

Inspirations (inhale) intercostal Retractions result during the respiratory effort to draw air into restricted airways

37. An elderly female client with dry flaky skin and activity intolerance secondary to myxedema is admitted to the progressive care unit to improve her activity tolerance and gain independence in self care. For hygiene care the nursing order is two total baths per week on Saturday and Wednesday with partial baths on the remaining days of the week. Which of the following would be the desired outcome of this intervention?

Intact elastic moist warm skin by the end of the first week

18. An 85 y/o client is brought to the ED after a fall at home. The client appears confused and malnourished and is severely dehydrated. The client can speak but appears reluctant to explain haw the fall happened. The client 62 y/o daughter frequently interrupts the client and does not allow the client to answer questions. Which of the following nursing interventions is a priority?

Interview the client alone at first and assess for abuse

17. The LVN is assessing the orientation of an elderly client. The client is unable to remember the year and reports being lost and unfamiliar with the surroundings. Which documentation is the most accurate for the LVN to make?

Is disoriented to time and place

8. The police accompany a client to the ED after the client tried to jump off a bridge. Which question is most important for the LVN to ask the client during admission to the mental health unit?

Is the client having hallucinations to harm other people

25. The LVN interprets the client's PPD as a positive skin test. Which drug is considered the primary prophylaxis for a client exposed to active tuberculosis?

Isoniazid

10. Which of the following is true of purified protein derivative (PPD) and TB

It is used to detect previous exposure of mycobacterium infection

26. The Chvostek's Sign is

It refers to abnormal reaction to the stimuli of facial nerves. Tapping the nerves

5. Escitalopram is prescribed for a 16 y/o adolescent client who is clinically depressed. Five days later, the parent tells the PN that the drug is not working because their child is not feeling any better. Which explanation should the LVN provide?

It takes 1 to 4 weeks for antidepressants medication to become effective

26. The LVN is assigned a client with a medical history of diabetes and gangrene who had an (R) below the knee amputation. At the time of rewarding and inspecting the stump, the client refuses to look at their stump. The LVN tells the client that the incision is healing well, but the client refuses to talk about it. What is the best response to this client's silence?

It's OK if you don't want to talk about your surgery. I will be available when you are ready.

1. A 32 y/o client has been grieving about their daughters death. The drunk driver killed the clients daughter 6 months earlier. Which statement by the client would indicate to the LVN that the client is improving?

Joining a support group

15. The LVN is examine a child's with a exacerbation of juvenile RA and notes that the child's mobility is greatly reduced. What factor should the LVN observe that affects the child's mobility?

Joint inflammation

The LVNis reinforcing teaching of a 14 y/o client regarding calcium intake. The client explains to the LVN they do not like milk. The LVN identifies which other foods that should be recommended to ensure adequate nutrition?

Kale and book choy

The LVN identifies which condition as one that has been closely associated with acquired immune deficiency syndrome?

Kaposi's sarcoma

12. Which action is most important for the LVN to implement when donning sterile gloves?

Keep gloved hands above the elbows Rational- gloved hands below elbows are considered unsterile

23. The nurse is caring for a male patient with a colostomy. When teaching the patient how to care for his colostomy, the nurse would instruct the patient that the MOST important intervention is to

Keep skin around the stoma area free of feces

9. Which of the following actions by the ruse comply with core principles of surgical asepsis? Select all that apply

Keep sterile field in view at all times Add contents to the sterile field holding the package 6 inches above the field

9. The hospitalized client with end-stage renal disease has expressed verbal and written wishes DNR. Which action should the LVN take?

Keep the client comfortable as possible Rational- client has the right to make decisions regarding their care, up to and including CPR measures. The LVN must respect the clients wishes while keeping client comfortable as possible

14. The LVN assesses the elderly client's skin for signs of breakdown and observes that the skin is intake. What interventions by the LVN will help maintain healthy skin integrity?

Keep the client well hydrated

49. After MRI t rule out an expanding brain lesion, the LVN prepares the client for slumber puncture. Client would include

Keeping clients head flat to avoid a headache

The facility for which the LVN works is undergoing a Magnet recognition journey, so the LVN has been asked to consider returning to school in order to meet educational requirements of the accreditation. The LVN looks at various nursing program, but is concerned due to a preference for assignments that involve more than just papers. The LVN wants to actively demonstrate knowledge and skills learned. Which type of learner is the LVN?

Kinesthetic learner

The LVN identifies a client has diminished breath sounds and adventitious breath sounds, weak radial pulses that are thready, and skin which is pale and cool to the touch. The client's capillary refill is +4. The client's oral mucosa and conjunctiva are cyanotic. The LVN also identifies that the client is SOB and tachypneic when ambulating. The S/S are most consistent with which condition?

Left sided heart failure

51. The LVN administered carbidopa levodopa to a client DX with Parkinson's disease. Which outcome by the client would indicate a therapeutic response?

Lessening of tremors

11. A client DX with Alzheimer's is wandering the busy halls of the extended care facility and asks the LVN where should I stand for the parade? Which response is best for the LVN to provide?

Let's go back to the activity room and see what's going on in there

12. The client has antisocial personality disorder and persists in asking for the address and other personal information about the nurse. The client states "I just want to get to know you better. You're the only one I can really talk too. What is the most effective response by the nurse>

Let's talk about my purpose in working with your feelings about it

28. A client DX with schizophrenia who has been taking the antipsychotic agent clozapine for the past 3 weeks has a low grade fever. Which nursing finding would have the greatest implications for this client's care?

Leukopnia Monitor WBC and deferential counts

20. A toddler is admitted for severe anemia, which is found to be dietary in nature. To increase iron in the diet as means of promoting healthy growth and development, the nurse recommends to the parents that they

Limit milk to no more than 32 oz/day

5. The nurse is admitting a client with a HX of grand mal seizures. As a precaution in case a seizure occurs, what equipment should the nurse ensure is placed in the room?

Linens to pad the bed rails and a suction machine

15. The LVN is collaborating with the nursing staff about the plan of care for a client who is very depressed. What is the most important intervention to implement during the first 48 hours after the admission to the inpatient unit?

Maintain safety

37. An elderly client is recovering from a myocardial infarction (MI) the cardiologist prescribes Docusate sodium with a dosage of one tablet by mouth twice a day. What therapeutic effect does this medication provide for this client?

Maintaining soft stool to prevent straining on defecation

61. A client is recovering from a MI. The cardiologist prescribes Docusate sodium 100mg PO bid. What therapeutic effect does this medication provide for this client?

Maintaining soft stools to prevent straining on defecation

50. A client prescribed an antacid for the treatment of peptic ulcer disease. What is the action of this medication that is effective in treating the clients ulcer?

Maintenance of a gastric pH of 3.5 or above

29. The nurse notes that a client receiving phenytoin daily has a serum phenytoin level of 14 mcg/ml. What intervention should the nurse implement?

Make sure that the client is performing through oral care

39. The pediatric clinic nurse explains to a parent that the child should receive the first dose of which vaccine at 12-15 months of age?

Measles, mumps, and rubella (MMR)

6. The client who has a long history of T!DM is being treated for bronchitis and sinusitis. The nurse observes deep, rapid, unlabored respirations, fruity odor on the clients clothes, and dry skin. Which of the following actions should the nurse take next?

Measure blood glucose level for hyperglycemia and check urine for ketones

36. A client is admitted from the ED with a DX of (L) tibia fracture and (L) leg has a splint in place. The client was medicated approximately 2 hours ago with a prescribed analgesic. The client is now complaining of excruciating leg pain and demanding "stronger pain medication" what initial action is most important for the LVN to take?

Measure the pulse volume and capillary refill distal to the fracture

22. An older adult with a 33 y/o history of bipolar disorder presents at the psychiatric outpatient clinic with diarrhea and confusion. What information is most important for the LVN to obtain?

Medication taken during the last week

70. A client has serum potassium level of 3 mEq/l. Which findings should the LVN report to the charge nurse? Select all that apply

Muscle cramping Dysrhythmias

42. The nurse educates the pregnant client about a new DX of gestation diabetes. Which statement made by the client indicates the need for further education?

My Dr will provide medication to control my blood sugars to normal levels

44. A pregnant client is being discharged after presenting to the labor an delivery unit in false labor. The nurse explains to the client the signs of true labor. Which statement made by the client indicates that further teaching is required?

My contractions will be irregular and felt in my abdomen

22. Which PRN medication would the nurse anticipate using when a client suspected to have taken too many narcotics and has a respiratory rate of approximately 8 bpm?

Naloxone ( Narcan)

45. The nurse explains to a new mother why the baby needs a vitamin K injection. Which statement by the mother indicates adequate understanding?

Newborn babies need vitamin K to prevent bleeding

56. A client DX with duodenal ulcers is admitted to the hospital. The client was administered ranitidine hydrochloride 150 mg PO at bedtime. Which finding old indicate a therapeutic response of the medication?

No complaints of heartburn or abdominal pain verbalized

17. A. Client with schizophrenia reports hearing voices that tell the client to walk in the middle of the street. Which statement indicates to the LVN that the client needs to continued hospitalization?

No matter what I do I cant make the voices go away

48. The LVN receives sift report on their assigned clients. Based on the change of shift report which situation has the highest priority?

No output in a hemovac from the abdominal incision of a client who is post-op day one.

3. An elderly client is seen in the clinic for problems with urinary frequency, urgency, and nocturia. The symptoms are an example of which condition?

Normal aging change

32. A newborn who has mild transitional (positional) clubfeet is placed in bilateral casts in an overcorrected valgus (outward) position. What is the primary issue the LVN should review with the parents during discharge teaching?

Observe for skin and circulation compromise from the cast

8. The teacher reports that a 7 y/o child frequently daydreams in school, experiences abrupt interruptions in conversations, and stares into space. Which action should the LVN take?

Observe the child's behavior in the class room Absence (petit mal) seizures are often manifested a daydreaming behaviors

5. A client DX with epilepsy is admitted to the unit. What intervention should the LVN implement if the client experience a seizure?

Observe the length and activity of the seizure

26. A Client DX with a UTI is prescribed an ampicillin. Which nursing intervention is most important for the LVN to do first before administering the client's medication?

Obtain a clean catch urine specimen

53. A client residing in a memory care nursing facility with a DX of diabetes approaches the nurse crying, saying " i just don't feel good" what action should the LVN take first?

Obtain a finger stick blood glucose test

38. An intravenous pyelogram IVP is ordered for a client who is scheduled to have his left kidney removed because of hypertension and renal disease. Which of the following nursing actions has the highest priority the evening prior to the IVP?

Obtain information about clients allergies

14. During a routine prenatal visit, a female at 38 weeks gestation tells the LVN that both her cousin and her cousin's 1 year old daughter have PKU. The client is concerned that her unborn child may have PKU and become mentally retarded. Which information should the LVN provide?

PKU screening is performed after the newborn ingest milk

18. The dosing of heparin IV infusion is guided by which lab value?

PTT (partial thrombophlebitis time)

28. The nurse is working in an OB office and is seeing a client who is 30 weeks pregnant with placenta pervia confirmed on ultrasound. Which of the following symptoms would the nurse attribute to placenta pervia?

Painless vaginal bleeding

5. After delivering a 9lbs 10 ounce baby, a client who is a gravida 5 para 5 is admitted to the postpartum unit. Priority nursing care for this client should be to

Palpate the fundus because she is at risk for uterine atony

The LVN identifies which as a contributing factor to the development of pressure ulcers?

Paralysis

28. Which parental behavior is warning to the LVN that there may be negative bonding between parents and newborn infant?

Parents that leave baby wrapped in blankets

The LVN is providing care to an older client and notices that the client walks with short, hesitated steps, along with a slow, shuffling motion and with very little arm movement. The LVN identifies that the client speaks in a very soft, low-pitched voice and has difficulty finding the right words and experiencing tremors at rest. Which condition most likely explains the client's behavior.

Parkinson's disease

The LVN is assisting in providing care to a client DX with preeclampsia. The LVN identifies and reports which sign is an indication that the client's condition is worsening?

Periorbital edema

47. A child with cystic fibrosis is receiving ticarcillin disodium for Pseudomonas pneumonia. What adverse effect should the nurse assess for and report promptly to the HCP?

Petechiae

33. A client who is receiving phenytoin begins to exhibit nystagmus and diplopia. The LVN identifies which physiologic manifestation as consistent with these findings?

Phenytoin toxicity

50. Which of the following ophthalmic medications would be indicated for the client with open angle glaucoma?

Pilocarpine (Pilocar)

26. The clients fetal heart rate is 150 before the contraction begins. During the contraction, the heart rate falls 110 and returns to baseline 30 seconds after the contraction ends. Which of the following is the priority nursing action in respo

Place the cleint in left lateral position

13. The nurse is to obtain pedal pulses on a client following a cardiac Catheterization. Which is the proper procedure?

Place the fingertips on top of the foot

24. In the client with right lung pneumonia, the nurse should encourage which of the following positions to facilitate oxygenation?

Position with left side dependent

27. A client with hypokalemia has been started on IV corticosteroids. Which of the following findings would indicate to the nurse a further decrease in calcium level in a client

Positive Chvostek's sign

The LVN is performing a focused assessment of a client with a right side hip fracture. The LVN suspects the client may have a fracture due to history associated with hip fractures?

Post menopausal status Reports of groin Right leg is internally rotated Limping present with amputation

2. 2 years ago a client was assaulted and robbed in a parking lot. Today the client verbalizes fear of parking lots and complains of reoccurring bad dreams about parking lots. The nurse should evaluate this behavior as a possible indicator of which problem?

Post-traumatic stress disorder. PTSD

The LVN is assisting the nurse with a client admitted with a DX of appendicitis. The LVN reports to the nurse that the client stated that their pain has suddenly stopped, and they feel much more comfortable. Which action should the LVN anticipate the nurse to perform?

Prepare the client for emergency surgery

23. An 18 month old toddler with a three day history of diarrhea was administered loperamide by their parent. What intervention is most important for the LVN to implement?

Question the parent how many wet diapers has the child had in 24 hrs

1. When reading a prescription, what should the LVN verify in addition to the "5 rights" of medication administrations?

Prescribers signature

28. An infant is born with a ventricular septal defect (VSD) and surgery is planned to correct the defect. The LVN should understand that the surgical correction is designed to achieve which hemodynamics outcome?

Prevent the return of oxygenated blood to lungs

19. A client DX with major depression was admitted to the psychiatric unit yesterday. Today the client wants to sleep during the day and refuses to take a bath, dress, or eat. Which intervention should the LVN implement first?

Provide and maintain a safe, structured daily routine

21. Just after delivery, a new mother tells the LVN that breastfeeding was unsuccessful with the clients first child, but the client would like to try with this baby. Which intervention should the LVN implement first?

Provide assistance to the mother to begin breastfeeding as soon as possible after delivery

36. The LVN is assisting with bathing an independent adult client who has plaster cast on the right forearm. Which action should the LVN implement to encourage self care by the client?

Provide back care and foot care as needed

4. A client of the mental health unit becomes very agitated and begins pulling pictures off the wall. The LVN asks for assistance to intervene and take the client to a quiet room away from other clients. What is the most important reason for removing the client to a quiet area away from others?

Provide safety to client and others

32. A representative of the hospital's accrediting agency is performing an on-site visit at the hospital and asked to see the nurses notes from a client's medical records. What action should the LVN take?

Provide the agencies representative with the information from the client's medical record

49. Which explaining the meaning of hospice care to a client, the nurse should include which information? Select all the apply

Provides specialized bereavement program Use kubler-Ross work on the stages of grieving

Which should the LVN identify as a normal finding on the physical exam of a neonate?

Pulsating anterior fontanelles

21. A client has been taking oral corticosteroids for the past 5 days because of seasonal allergies. Which assessment finding is of most concern to the LVN?

Purulent sputum Rational - steroids cause immunosuppression and purulent sputum is an indication of infection, so this symptom is of greatest concern

29. The LVN is caring for a child with Wilms' tumor. Which preoperative intervention should the LVN implement?

Put a sign above the bed reading " do not palpate abdomen" Minimize palpitations to prevent risk of rupturing the encapsulated tumor

2. To administer a saline enema to a client, the LVN inserts the enema tubing 3 inches into the client's rectum and elevates the saline container 6 inches above the client's body. After the LVN opens the clamp, the saline solution does not infuse. What is thee best action for the LVN to take?

Raise the saline container 6 more inches above the body Rational- the saline needs to be 12 inches above the body to infuse

24. A client DX with a sinus infection is prescribed ampicillin sodium. The LVN should instruct the client to notify the HCP immediately if which symptom occurs?

Rash

46. While sitting at a table talking to the LVN, the client lens over and begins hyperventilation. What action should the LVN initiate? Select all that apply

Reassure the client by encouraging slow deep breathing Assess the client for physical symptoms Remove client to a quiet area

70. A healthy 68y/o client asks the LVN should they take the pneumococcal vaccine. Which statement should the LVN offer to the client that provides the most accurate information about this vaccine?

Recommend for children 2-65 y/o

3. A client demonstrates pupillary constriction when a pen light was shine i their eyes. Which nursing action should the LVN perform?

Record the findings on the assessment notes

30. While examining a 6 y/o visiting the clinic for fever and a rash, the LVN notices several elevated 1-3 mm white spots on the buccaneers mucosa. What other signs should the LVN expect this child to exhibit?

Red blotchy macular rash on the face

9. The LVN is preparing a child with a intussusception for a prescribed barium enema. The LVN should explain to the parent that the purpose for conducting this procedure before surgical intervention is to achieve what objective?

Reduce the invaginatd bowel segment intussusception- is Telescoping of one portion of the intestine into another, causing blockage

69. A client who takes metformin for T2DM is NPO for surgery. The LVN anticipates which preop prescription for this client's glucose management?

Regular insulin subcut per sliding scale

While preforming a focused assessment on a client's skin turner, the LVN lifts up a fold of the client's skin. Which action should the LVN take next?

Release, observe the skin return to place

55. Phenazopyridine is commonly prescribed for clients withUTI. Which statement by the LVN describes the purpose for the administration of Phenazopyridine?

Relieves the symptoms of UTI

22. An adult client is admitted to the ED with partial thickness and full thickness burns over 40% of the body surface area resulting from a care collision fire. While the HCP and nurse are preparing to intubate the client, which intervention should the LVN do first?

Remove all the clients clothes, shoes and jewelry

22. The LVN is performing nasotracheal suctioning. After the client's tracheal is suctioned for 15 seconds, large amounts of thick yellow secretions return. What action should the LVN implement next?

Reoxygenate the client before attempting to suction again

A client with an indwelling urinary catheter arrives at the ED due to an inability to void. Prior to performing and assessment , the HCP discloses that no narcotics will be administered, citing a history of narcotic misuse. After a brief exam by the HCP that does not include diagnostic labs, medical test, or treatment, the LVN is being told that the client is to be discharged. The LVN should do which action?

Report the HCP inactions to the lead nurse

48. Minocycline 50 mg PO q 8 hrs is prescribed for a 18 y/o adolescent girl DX with acne. The nurse discusses self care with the client while she is taking the medication. Which teaching points should be included in the discussion? Select all that apply

Report vaginal itching or discharge Protect skin from natural and artificial ultraviolet light Avoid driving until response to medication is known Use a non hormonal method of contraception if sexually active

A LVN is cleaning the urethral meats of a client in preparation for inserting a urinary indwelling catheter. During the procedure, one of the two remaining sterile povidone-iodine swab falls from the catheter kit onto the client's bed without contaminating the sterile field. Which nursing action should happen next?

Request another sterile swab be placed into the sterile field

36.The nurse is caring for a client with pneumonia. Which of the following nursing observations would indicate a therapeutic response to the treatment?

Respirations at 20 with no complaints of dyspnea, moderate amount of thin white sputum

12. The nurse has been instructed to have a surgical consent from signed by a client who will be undergoing a surgical procedure. What is the most essential information to include in the discussion prior to the client signing the permission?

Right to withdraw consent

The LVN is reinforcing teaching to a client on fertility awareness methods. Which condition is a potential disadvantage of using these methods?

Rigorous daily monitoring

30. A LVN is reviewing the plan of care for client who is prescribed glucocorticoid methylprednisolone. Which nursing DX is related to this medication?

Risk for infection

23. When trying to obtain the best sputum specimen, which direction should the nurse include when teaching the client how to collect the specimen?

Save your first morning specimen, since it is the most concentrated

25. The nurse observes a client who is fidgeting, wringing the hands, and has body tenseness and a wrinkled brow. What is the best way for the nurse to interpret these nonverbal cues?

Say, you look tense. Can you tell me if something is making you afraid or nervous.

42. During a clinic visit, a client reports to the LVN that they felt a solid mass in their breast during a self examination, but it wasn't painful. What instruction should the LVN reinforce with the client?

Schedule an appointment with the HCP for evaluation Painless breast mass is abnormal

40. A client DX with asthma is prescribed methylprednisolone 40 mg IV daily. Which lab test results should the LVN closely monitor for increase values?

Serum glucose Corticosteroids effect blood sugars

61. The LVN is preparing a room for a client being admitted from the ED with a DX of new onset of seizures. Which intervention should the LVN implement first?

Set up and check for functioning of a suction apparatus and oxygen delivery system at bedside

9. A client with severe Parkinson's disease DX with anorexia, dysphagia, drooling, generalized weakness, and slurred speech is admitted to the unit. Which nursing action should the LVN implement for this client?

Set up suction and Yankauer at clients bedside

38. A nurse is concerned about maintaining the standards for client confidentiality. The nurse can perform the duties of the position and still maintain client confidentiality by

Sharing information about the client with those involved in planning nursing care

37. A client DX with hypertension is prescribed a low sodium diet. Which food choices selected from the hospitals menu demonstrate to the LVN that the client understands their dietary restrictions?

Skim milk, turkey salad, vanilla ice cream

The LVN is performing a focused assessment on a client who has been DX with peripheral artery disease. The LVN identifies a weak popliteal pulse. What are expected findings in the extremity distal to the weak pulse?

Skin is cool to touch and shinny in appearance Client reports numbness and achiness in leg Extremity has decreased hair growth Capillary refill is greater than 4 seconds

32. The nurse working in the community health clinic is assessing risk factors that can decrease medication effectiveness for clients DX with schizophrenia. Which client behavior is likely to decrease the effectiveness of psychotropic medications?

Smokes at least 20 cigarettes daily

15. Which serum laboratory value should the LVN monitor carefully for a client who has a nasogastric tube to suction for the past week?

Sodium

3. A client DX with bacterial pneumonia is being admitted to the unit from the ER. Which intervention should the PN ensure that it has been donee prior to the administration of antibiotics?

Sputum specimen

46. The nurse has emptied a Jackson Pratt wound drainage device and needs to reestablished suction to the tub. Which of the following actions should the nurse take to accomplish this objective?

Squeeze the collection chamber

15. The LVN performs a skin assessment on an elderly client who is on bed rest. The LVN notes a circular area of non-blanchable erythema on the coccyx. Which type of skin condition does this indicate?

Stage 1 pressure ulcer

32. A nurse examines a client and finds the client is using accessory muscles to breathe; respirations are 27 bpm. Two hours previously, this client was eugenic. What should the nurse do next?

Stay with the client, call the charge nurse for help, call the CNA to bring a pulse oximeter and blood pressure monitor to the room

The nurse initiated an IV transfusion of packed red blood cells to a client with sickle cell anemia. Shortly after the transfusion had started, the LVN identifies that the client has become very agitated, tachypneic, and reports lower back pain. Which action should the LVN implement first?

Stop the blood transfusion

A client was treated three days ago for puncture wound of the left lower calf. The client returns to the clinic with increased pain, limited ROM in the left leg, and overall achiness and chills. As the LVN assess the wound, what indicates possible infection?

Streaking Increased Redness Purulent drainage

31. The LVN enters a clients room and finds the client on the floor after a fall. How should the LVN communicate this situation to the risk manager team?

Submit a complete incident report describing the situation to the unit manager.

41. The supervisor observes a new graduate nurse suctioning a client who has a tracheostomy. Which of the following techniques indicate that the graduate nurse is caring out the procedure correctly?

Suction is applied for 10-15 seconds

35. The client is being observed for the risk of increasing intracranial pressure (ICP)

Suction through the nose is not recommended for clients who have head injuries

2. A client a 30 weeks gestation is on bed rest at home because of increased blood pressure. The home health nurse has taught her how to take her own B/P. When the client calls the clinic complaining of indigestion and headache, which information is best for the LVN to provide?

Take B/P and if it has significantly increased, go to the hospital immediately

30. When teaching a client about management following cataract removal with lens implant surgery, the nurse should include which of the following?

Take a stool softer and or laxative daily to prevent constipation No lifting or blending over for at least 6 weeks

41. The LVN determines that a client's radial pulse is irregular. What action should the LVN take next?

Take an apical pulse for 1 minute to verify irregularities

39. An older client is discharged from the hospital with a prescription of digoxin 0.25 mg daily. Which instructions should the LVN include in this client's discharge teaching plan?

Take and record radial pulse rate daily

66. Daily dose of alendronate is prescribed for a 54 y/o postmenopausal client. Which instruction should the LVN provide to this client regarding taking the prescribed medication?

Take medication 30 min before breakfast and remain in a upright position for 30 min after taking the mediation

The LVN is reinforcing teaching to a client about monitoring basal body temperature as a means to track fertility. The LVN identifies which action is recommended to improve basal body temperature accuracy?

Take temperature at the same time every day

23. The LVN is assessing several client's before surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery?

Taking anticoagulants for the past year

45. Which assessment findings indicate to the LVN that the client is no longer experiencing stress? Select all that apply

Talking and laughing with family in the waiting room Checking cell phone for messages Exhibit a lower than normal B/P Stating a recent interest in sexual desire

Modular nursing is used on the nurses unit. The LVN recognizes modular nursing as a modification of which client care delivery model?

Team nursing

5. A client's comes to the OB clinic for her first prenatal visit and complains of feeling nauseated every morning. The client tells the LVN I'm having second thoughts about wanting to have this baby. Which response is best for the LVN to make?

Tell me about the second thoughts you are having about this pregnancy

37. While reviewing the side effects of a newly prescribed medication, a 72 y/o client notes that one of the side effects is a reduction in sexual drive. What is the best response by the LVN?

Tell me how you think this might effect your present sexual activity

12. A client is admitted to the mental health unit with a chief complaint of crying, depressed mood, and sleeping difficulties. While talking about the death of a friend, the client states " I cant believe this happen" which statement by the LVN is most therapeutic?

Tell me more about how your feeling

58. A client DX with ovarian cancer ha just been informed that their cancer has mastastasized to their liver. The client is quietly crying in their room. Which statement for the LVN to say?

Tell me what you are feeling right now

Which approach should the LVN. Take when reinforcing teaching to a 12 y/o client about puberty?

Tell the client that changes are normal and healthy

21. A male client DX with an antisocial personality is complimenting the female nurse about her hair, soft skin and beautiful eyes in a group meeting. What action should the LVN take?

Tell the client that the client is being inappropriate and to please stop

35. An elderly female client DX with advanced dementia is admitted to the hospital with a fractured hip. The client repeatedly tells her staff "take me home. I want my mommy" which response is best for the LVN provide?

Tell the client that the nurse is there and will help her

4. The LVN observes the UAP placing a tongue blade at the bedside of the child admitted with seizures disorder. Which intervention should the LVN implement?

Telling the UAP that tongue blades should not be inserted during a seizure

When doing an assessment of sensory nerve function, which test should the LVN omit if the pain sensation is normal?

Temperature

36. A 12 y/o with T1DM complains of abdominal pain and has experienced increased thirst during the previous 24 hours. What action should the LVN implement first?

Test urine for ketones and glucose

16. A LVN is reviewing teaching with the client and/or significant others about the concurrent use of benztropine and olanzapine to manage psychotic behavior. What information should the LVN reinforce?

The benztropine is used to control the side effects of olanzapines

8. A client with acute leukemia is admitted for a bone marrow transplant. The nurse concludes that the client understands teaching based on which of the following statements?

The bone marrow is given through IV line

63. A client has been DX with open angle glaucoma. The HCP prescribes pilocarpine 1% eye drops. What action of the drug makes it useful treatment for the client's condition?

The ciliary muscle contracts increasing the outflow of aqueous humor in the eye

8. The nurse knows the client receiving a narcotic analgesic via a PCA pump and his family understands instructions when they relate

The client alone is allowed to administer the medication

18. A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement should the LVN identify that best demonstrates the client's readiness to manage his/her wound care after discharge?

The client demonstrates the wound care procedure correctly

15. Which of the following indicates to the nurse a need for further teaching for a postoperative client using the incentive spirometer?

The client exhales with the spirometer in his mouth

7. A client receiving the medication haloperidol. Which client data would indicate to the LVN that the medication is therapeutic?

The client has demonstrates a decrease in paranoia behaviors Antipsychotic neuroleptic medication

58. A client is prescribed sildenafil for pulmonary hypertension calls the clinic for advice. Which condition should the LN notify the HCP immediately and instruct the client to stop taking the medication?

The client is experiencing vision and hearing loss

The visiting LVN is performing a focused assessment with a client with early stage dementia who has recently been prescribed donepezil (Aricept) which information obtained from the client's family member demonstrates that the prescribed medication is effective?

The client is showering and dressing with minimal assistance

A client arrives to the ED via ambulance for a suspected stroke. According to the client's spouse, the stroke-like symptoms occurred approximately 1.5 hours ago. An IV of 0.9% NS is infusing at 75ml/hr. The client has no airway compromise and no arrhythmias has been detected. Admission blood work has been drawn and sent to lab. The LVN anticipates what is the next plan of action in the client's care?

The client is transported to radiology for CT scan without contrast.

21. The nurse in the outpatient client teaches a client with right side weakness to walk down the stairs using a cane. What behavior, if demonstrated by the client, would indicate that the teaching was successful?

The client leads with the cane, followed by her right leg, and then her left leg

1. When teaching safety precautions to the client with an internal radiation implant, the nurse would include which of the following in explanations to the client

The client poses a risk of radiation exposure to others Wear proper PPE

14. A client DX with lymphoma is receiving chemotherapy. The client's hemoglobin is currently 6 g/dl. The LVN assigns UAP to provide personal hygiene for this client. What instruction should the LVN provide to the UAP?

The client will be weak and unsteady and tire easily

13. A plan of care for a 56 y/o client who has been DX with osteopenia has been developed. The plan is focused on preventing further bone resorption and increasing bone mass. Which outcome statement should be included in the plan of care?

The client will decrease the number of cigarettes smoked by 50% within 2 weeks

A client with delirium keeps attempting to get out of bed and has fallen twice, despite being under close observation. The charge nurse calls the HCP to obtain a prescription for mechanical restraints. Which statement is correct regarding the mechanically restraint policy?

The client will need to remain on close observation with documentation note every 15 minutes

8. A client DX with vaginal trichomoniasis is prescribed oral metronidazole. What instructions should the LVN review with the client while taking this medication?

The client's sexual partner(s) should also be treated

42. An older client is receiving hospice care and the spouse and family have expressed several concerns. Which concern expressed by thee family should the LVN address first?

The client's spouse wants to know when to call 9-1-1

30. Which client finding requires further action by the LVN?

The drainage tube of an indwelling catheter is looped below the client's bladder

Urolithasis

The formation of stony concentration in the bladder or urinary tract

27. An infant is placed in a Pauli's harness for development dysplasia of the hip. The nurse has completed parent teaching, but the parents seem to be overwhelmed by the condition and make several statements indicating a lack of understanding. The statements that indicate more teaching is needed are: select all that apply

The straps of the harness should be placed next to the skin The harness should be worn for 6 hours a day It will take a long time for my child to walk or crawl

A parent approved lesson about "prevention transmitting herpes simplex virus 2 (HSV-2) was presented to a group of adolescent students. Which statement from one of the students would identify a proper understanding of the lesson?

There is currently no cure for HSV-2

18. A client has a chest tube inserted for a pneumothorax. The nurse monitors the drainage system for adequacy. Which of the following signifies that the system is working correctly?

There is fluctuation in the water seal compartment coinciding with respirations Increases with inspiration and falls with expiration

17. The LVN reinforces nutritional counseling to a group of clients with diabetes. What is the most important purpose of a diabetic diet?

To normalize the blood glucose level through a balanced diet

59. A client with DX of DM and gastroesophageal reflux disease is newly prescribed propranolol for hypertension. Which information should the nurse provide to this client?

To use glucometer frequently throughout the day

18. A child with nephrotic syndrome is receiving prednisone. The LVN reviews breakfast foods at a fast food restaurant with the child's mother. Which selections indicate that the mother understands the dietary guidelines necessary for her child?

Toasted oat cereal and low fat milk

43. The LVN is reviewing the health histories of the following individuals. Which factor does have the potential for development of throat cancer?

Tobacco use

14. The client had abdominal surgery 5 weeks ago, and now is having leg pains. What activities could the nurse have performed when the client was hospitalized that would have minimized this complications risk? Select all that apply/

Turn client q 2 hrs Avoid crossing legs Instruct the client to wear pneumatic compression devices while in bed

40. A primary consideration by the nurse in preop teaching for prevention of atelectasis would be to educate the client about

Turning, coughing, and deep breathing q 2 hrs

The HCP recommends that a client take 10ml of anOTC liquid cold prescription. The LVN should instruct the client to take how much of the medicine using a household measuring device?

Two teaspoons 1 tsp = 5ml 5+5=10

8. The LVN is teaching a couple about ovulation an conception. Which statement by the LVN gives the most likely time for conception to occur?

Two weeks before mensturation

10. An older client DX with BPH asks the LVN what will happen if he decides not to have TX. Which information given by the LVN is most accurate regarding BPH?

Untreated BPH causes urinary reflux and possible hydronephrosis

24. The LVN is caring for a client who is having an exacerbation of CHF. The LVN should place the client in which position?

Upright, with the legs in a dependent position Rational- upright with feet dangling over the side of the bed. (CHF or pulmonary edema clients)

39. The nurse is collecting data on a client admitted with 2nd and 3rd burns on the face, arms, and chest. Which finding indicates a potential problem?

Urine output 20 ml hr

The LVN is reviewing the data of a client who reports severe, spasmodic pain in the right flank. The pain is intermittent and is accompanied by nausea and diaphoresis. The client has a history of gout. On inspection, the client's urine has a pink and cloudy appearance. The client denies any fever or chills and is presently afebrile. The clients symptoms are most consistent with which condition?

Urolithasis

35. What is the most important information for the LVN to review with a 12 y/o who is receiving long term and rescue medications for routine management of asthma?

Use albuterol for prevention of exercise induced brochospams

9. The LVN is interviewing a client who reports having angry outburst and difficulty controlling mood changes and denies hearing voices or having suicidal thoughts. What information is most important for the LVN to obtain?

Use of medications or substances

24. In interviewing a pregnant client concerning sexually transmitted infections, the nurse should recognize which of the following as a barrier to client disclosure?

Use of only yes or no questions

23. The newly delivered infant has been placed on the mothers abdomen. The priority nursing intervention for the newborn is to do which of the following?

Use the bulb syringe to clear the mouth and nose of mucus

The LVN is caring for a client with COPD which has resulted in chronic state of partially compensated respiratory acidosis. The LVN is reinforcing client teaching about ways to improve respiratory status. Which should be included in the reinforcement of teaching?

Used pursed-lip breathing

22. In teaching clients about measures to reduce the risk of developing basal cell carcinoma, the nurse should include which of the following?

Using sunscreen with protection SPF of 15 or greater when exposed to the sun

3. The LVN is assessing a client at 20 keeps gestation. Which measurement should be compared with the client's current weight to obtain data about her weight gain during the entire pregnancy?

Usual prepregnancy weight

The HCP prescribed a treatment for chronic wound that utilizes a technique which uses a special sponge that is placed in the wound for 48 hours with a continuous low-level negative pressure. The LVN recognizes the client will need to be prepared for which procedure?

Vacuum assisted closure

46. A 2 month old infant is scheduled to receive the first DPT immunization. What is preferred injection site to administer this immunization?

Vastus lateralis

71. Which educational materials should the LVN select for reinforcing teaching for secondary prevention?

Video that teaches client to do breast self exams Pamphlets describing haw to do testicular self exams Postcard reminders for a client to get Pam smears and mammograms

2. The nurse would take which of the following actions to comply with principles of medical asepsis? Select all that apply

Wash hands before and after assisting a client with personal hygiene Wear gown and gloves when working with a client on contact precaution

9. An elderly client calls the clinic reporting weakness and dizziness. Further assessment by the LVN indicates that the client self administered an enema of 3 liters of tap water to relieve constipation. What is the most likely cause of clients symptoms?

Water intoxication

A client with stage 3 Alzheimer's disease is living with his son and daughter in law. The visiting LVN is reforming teaching to the family about the progression of illness, including "sundowners syndrome" and is assisting with strategies and comfort measure. The LVN recognizes which statement by the daughter in law reflects that the teaching has been effective?

We will have locks placed at the top of all the outside doors

21. The mother of a 5 y/o child with recurrent Tinea pedis asks the nurse how the child got the condition. After talking with the mother about the child's habits, the nurse determines that which of the following would be the most likely cause?

Wearing rubber boots with moist feet several days in a row

19. In caring for a client with acute HEP B, the client says " I am so tired of this bed. I don't think I can stay here any longer" the best response of the nurse is

What activity do you think you can do without getting too tired?

The LVN observes that multiple assigned tasks were left incomplete at the end of shift on the unit. The LVN the provides feedback to a newly hired UAP regarding strategies for improvement. The LVN identifies which statement by the LVN demonstrates the use of reflective encouragement?

What are some things that could have been handled differently

37. A high speed graduate with ADHD presents to the family HCP for a precollege physical exam and tells the LVN " I don't want to take my amphatamine-dextroamphetamine in college. How should the LVN respond?

What are your concerns about continuing Adderall?

15. A female client has been DX with a dependent personality disorder. Which statement is likely to be her response to the nurses suggestion that she complete her morning care?

What do yo think I should wear?

24. When questioned by a client about what an advance directive or living will is, the nurse should respond that 'tis type of document indicates

What treatment should be provided or omitted if the client becomes incapacitated

60. A client DX with status asthmatic is admitted to the unit. Which breath sounds would the LVN anticipate to hear when auscultating the client's lungs?

Wheezes

35. The nurse concludes that a 67 y/o client is exhibiting normal growth and development according to Erickson's theory of development after the client makes which statement?

When i get older, I hope I am able to care for myself. If I have to die, I hope its quick in my sleep

16. The LVN teaches the client how to administer regular and NPH insulins and request a return demonstration from the client. Which action by the client indicates understanding of the medication instruction?

When racing up insulin in the same syringe, the client drew up the regular (clear) insulin first and then the NPH (cloudy) insulin

23. During an admission interview, a client reports using alcohol and other illegal drugs every day for the last 3 years. What question is most important for the LVN to ask this client?

When was the last time you used alcohol or drugs

A client DX with obsessive compulsive personality disorder with a comorbid depression has be receiving dialectic behavior therapy (DBT). The LVN identifies which statement by the client indicates that thee treatment has been effective?

Yoga and deep breathing help me when I get anxious about upcoming family visit

14. A delirious client was recently released from wrist and ankle restraints. Suddenly, the client begins to beat the sheet and yell, "Get those bugs away from me" They're all over me" Get them" The best initial response by the nurse is

You are seeing bugs because you are sick, but I don't see any bugs on you

9. While taking a client's history, the LVN discovers that the client, who takes warfarin daily for atrial fibrillation, has added St. John's wort to their daily regime. What recommendation should the LVN provide to this client?

You need to discontinue the use of the herb and consult with your HCP

29. The client with newly DX Parkinson's states, " I just don't think I can handle having Parkinson's disease." What is the nurses best response ?

You sound overwhelmed. Can you tell me more?

19. A new mother asks the LVN "How do I know that my daughter is getting enough breast milk?" Which explanation best supports that the mother has adequate milk supply?

Your milk is sufficient if the baby is voiding pale straw colored urine 6-10 times a day

35. Before performing a fecal occult blood test or guaiac test on a stool specimen, the LVN should ask the client about regular use of which vitamin?

vitamin C