LVN Fundamental 3
A 2-g sodium diet is prescribed for a client with stage 2 hypertension, and the nurse teaches the client the rationale for this diet. The client reports distaste for the food. The primary nurse hears the client request that the family "bring in a ham and cheese sandwich and fries." What is the most effective nursing intervention? 1. Discuss the diet with the client and family. 2. Tell the client why salty foods should not be eaten. 3. Explain the dietary restriction to the client's visitors. 4. Ask the dietitian to teach the client and family about sodium restrictions.
Answer: 1. Discuss the diet with the client and family Reason: The client and significant family members should be included in dietary teaching; families provide support that promotes adherence. The client already has received information about why salty foods should not be eaten. Explaining the dietary restriction to the client's visitors could violate confidentiality. The client should be involved in his or her own care; the client ultimately will assume the responsibility. The dietitian is a resource person who can give specific, practical information about diet and food preparation once there is a basic understanding of the reasons for the diet.
A complete blood count (CBC), urinalysis, and x-ray examination of the chest are prescribed for a client before surgery. The client asks why these tests are done. Which is the best reply by the nurse? 1. "Don't worry; these tests are routine." 2. "They are done to identify other health risks." 3. "They determine whether surgery will be safe." 4. "I don't know; your health care provider prescribed them."
Answer: 2. "They are done to identify other health risks" Reason: Certain diagnostic tests (e.g., CBC, urinalysis, chest x-ray examination) are done preoperatively to rule out the existence of health problems that may increase the risks involved with surgery. Feelings will not be dispelled by telling the client not to worry; it also blocks further communication. Surgery poses a risk despite test results. Lack of knowledge without a statement of plans to obtain the information suggests incompetence on the part of the nurse.
The physician orders intravenous fluids to be infused at 100 mL/hour. The intravenous tubing delivers 15 drops/milliliters. The nurse would infuse the solution at a flow rate of how many drops per minute to ensure that the client receives 100 mL/hour? Record your answer using a whole number. _____ gtts/min.
Answer: 25 gtt/min
An intravenous (IV) solution of 1000 mL 5% dextrose in water is to be infused at 125 mL/hr to correct a client's fluid imbalance. The infusion set delivers 15 drops/mL. To ensure that the solution will infuse over an eight-hour period, at how many drops per minute should the nurse set the rate of flow? Record the answer using a whole number. ______ gtts/min
Answer: 31 gtt/min
The health care provider orders 1000 mL normal saline to be infused over 8 hours for a client with a diagnosis of dehydration. The intravenous (IV) tubing delivers 15 drops per milliliter (drop factor). The nurse should administer the IV infusion at a rate of ____ gtts/minute. Record your answer using a whole number.
Answer: 31 gtt/min
What response should a nurse be particularly alert for when assessing a client for side effects of long-term cortisone therapy? 1. Hypoglycemia 2. Severe anorexia 3. Anaphylactic shock 4. Behavioral changes
Answer: 4. Behavioral changes Reason: Development of mood swings and psychosis is possible during long-term therapy with glucocorticoids because of fluid and electrolyte alterations. Hypoglycemia, severe anorexia, and anaphylactic shock are not responses to long-term glucocorticoid therapy.
A nurse is teaching members of a health care team how to help disabled clients stand and transfer from the bed to a chair. To protect the caregivers from injury, the nurse teaches them to lift the client by first placing their arms under the client's axillae and next: 1. Bending and then straightening their knees 2. Bending at the waist and then straightening the back 3. Placing one foot in front of the other and then leaning back 4. Placing pressure against the client's axillae and then raising their arms
Answer: 1. Bending and then straightening their knees Reason: The leg bones and muscles are used for weight bearing and are the strongest in the body. Using the knees for leverage while lifting the client shifts the stress of the transfer to the caregiver's legs. By using the strong muscles of the legs the back is protected from injury. Bending at the waist and then using the back for leverage is how many caregivers and people who must lift heavy objects sustain back injuries. The anatomical structure of the back is equipped only to bear the weight of the upper body. By leaning back, the client's weight is on the caregiver's arms, which are not equipped for heavy weight bearing. The caregiver's arms are not strong enough to lift the client. In the struggle to lift the client, the client and caregiver may be injured.
To decrease abdominal distention following a client's surgery, what actions should the nurse take? (Select all that apply.) 1. Encourage ambulation 2 . Give sips of ginger ale 3. Auscultate bowel sounds 4 . Provide a straw for drinking 5 . Offer an opioid analgesic
Answer: 1. Encourage ambulation 3. Auscultate bowel sounds Reason: Ambulation will stimulate peristalsis, increasing passage of flatus and decreasing distention. Monitoring bowel sounds is important because it provides information about peristalsis. Carbonated beverages, such as ginger ale, increase flatulence and should be avoided. Using a straw should be avoided because it causes swallowing of air, which increases flatulence. Opioids will slow peristalsis, contributing to increased distention.
What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? 1. If the client is allowed to give consent. 2. The client cannot make informed decisions about health care. 3. If the client is permitted to give voluntary consent when parents are not available. 4. The client probably will be unable to choose between alternatives when asked to consent.
Answer: 1. If the client is allowed to give consent. Reason: A person is legally unable to sign a consent until the age of 18 years unless the client is an emancipated minor or married. The nurse must determine the legal status of the adolescent. Although the adolescent may be capable of intelligent choices, 18 is the legal age of consent unless the client is emancipated or married. Parents or guardians are legally responsible under all circumstances unless the adolescent is an emancipated minor or married. Adolescents have the capacity to choose, but not the legal right in this situation unless they are legally emancipated or married.
A health care provider prescribes a vitamin tablet that contains vitamin B complex. What should the nurse teach the client? 1. It may turn the urine bright yellow. 2. The daily fluid intake should be increased. 3. The drug should be taken on an empty stomach. 4. It may accumulate in the body if an excessive amount is taken
Answer: 1. It may turn the urine bright yellow Reason: Bright yellow urine is an expected, insignificant side effect of vitamin B complex. There is no need to increase oral fluids; the client may consume the usual daily intake of fluid. Taking the drug on an empty stomach may precipitate nausea; therefore, it should be taken with food. Vitamin B complex is a water-soluble vitamin, and excess amounts are excreted in urine.
A client is admitted to the hospital for an elective surgical procedure. The client tells a nurse about the emotional stress of recently disclosing being a homosexual to family and friends. What is the nurse's first consideration when planning care? 1. Exploring the client's emotional conflict 2. Identifying personal feelings toward this client 3. Planning to discuss this with the client's family 4. Developing a rapport with the client's health care provider
Answer: 2. Identifying personal feelings toward this client Reason: Nurses must identify their own feelings and prejudices because these may affect the ability to provide objective, nonjudgmental nursing care. Exploring a client's emotional well-being can be accomplished only after the nurse works through one's own feelings. The focus should be on the client, not the family. Health team members should work together for the benefit of all clients, not just this client.
A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? 1. Famotidine (Pepcid) 2. Methyldopa (Aldomet) 3. Ferrous sulfate (Feosol) 4. Levothyroxine (Synthroid)
Answer: 2. Methyldopa (Aldomet) Reason: Methyldopa is associated with acquired hemolytic anemia and should be discontinued to prevent progression and complications. Famotidine will not cause these symptoms; it decreases gastric acid secretion, which will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red blood cell destruction.
A client reports severe pain two days after surgery. After assessing the characteristics of the pain, which initial action should the nurse take next? 1. Encourage rest. 2. Obtain the vital signs. 3. Administer the prescribed analgesic. 4. Document the client's pain response.
Answer: 2. Obtain the vital signs Reason: Immediately before administration of an analgesic, an assessment of vital signs is necessary to determine whether any contraindications to the medication exist (e.g., hypotension, respirations ≤12 breaths/min). Pain prevents both psychological and physiological rest. Before administration of an analgesic, the nurse must check the health care provider's prescription, the time of the last administration, and the client's vital signs. A complete assessment including vital signs should be done before documenting.
A nurse provides crutch-walking instructions to a client that has a left-leg cast. The nurse should explain that weight must be placed: 1. In the axillae. 2. On the hands. 3. On the right side. 4. On the side that the client prefers
Answer: 2. On the hands Reason: Body weight should be placed on the hands and not under the arms in the axillae when a client is walking with crutches to prevent damage to the brachial plexus nerves and prevent "crutch paralysis." Placing weight in the axillae during crutch walking is incorrect. Weight during walking with two crutches should be distributed equally to both sides of the body without regard to the unaffected side or either side.
A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force? 1. Maintain the head of the bed at 35 degrees or less. 2. With the help of another staff member, use a drawsheet when lifting the client in bed. 3. Reposition the client at least every 2 hours and support the client with pillows. 4. At least once every 8 hours, perform passive range-of-motion exercises of all extremities.
Answer: 2. With the help of another staff member, use a drawsheet when lifting the client in bed Reason: Shearing force is the pressure exerted on the skin when a debilitated client is pulled up in bed without a drawsheet, or when the client slides down in bed. With shearing, the skin adheres to the bed linens while the layers of subcutaneous tissue and bone slide in the direction of the body movements, causing a tearing of the skin. Using a drawsheet can reduce and minimize friction and shearing force. Maintaining the head of the bed at 35 degrees or less, repositioning the client at least every 2 hours and supporting with pillows, and, at least once every 8 hours, performing passive range-of-motion exercises of all extremities are all appropriate interventions to prevent further pressure injury and to promote circulation, but they are not as effective as using a drawsheet in prevention of shearing force.
A client who is HIV positive is admitted to a surgical unit after an orthopedic procedure. The nurse should institute appropriate precautions with the awareness that HIV is highly transmissible through: (Select all that apply.) 1 . feces. 2 . blood. 3 . semen. 4 . urine. 5 . sweat. 6 . tears
Answer: 2. blood 3. semen Reason: HIV, which is the virus that causes AIDS, is transmitted through infected blood, semen, and bloody body fluids. HIV is not spread casually. Although HIV may be found in other body secretions, including feces, urine, sweat, tears, saliva, sputum, and emesis, the amount of virus is likely not sufficient enough to be transmitted.
The family of an older adult who is aphasic reports to the nurse manager that the primary nurse failed to obtain a signed consent before inserting an indwelling catheter to measure hourly output. What should the nurse manager consider before responding 1. Procedures for a client's benefit do not require a signed consent. 2. Clients who are aphasic are incapable of signing an informed consent. 3. A separate signed informed consent for routine treatments is unnecessary. 4. A specific intervention without a client's signed consent is an invasion of rights.
Answer: 3. A seperate signed informed consent for routine treatments is unnecessary Reason: This is considered a routine procedure to meet basic physiological needs and is covered by a consent signed at the time of admission. The need for consent is not negated because the procedure is beneficial. This treatment does not require special consent.
A client has undergone a subtotal thyroidectomy. The client is being transferred from the post anesthesia care unit/recovery area to the inpatient nursing unit. What emergency equipment is most important for the nurse to have available for this client? 1. A defibrillator 2. An IV infusion pump 3. A tracheostomy tray 4. An electrocardiogram (ECG) monitor
Answer: 3. A tracheostomy tray Reason: The client who has undergone a subtotal thyroidectomy is at high risk for airway occlusion resulting from postoperative edema. With this in mind, emergency airway equipment such as a tracheostomy set and intubation supplies should be immediately available to the client. A defibrillator, an IV infusion pump, and an electrocardiogram (ECG) monitor are all equipment items that should be available to all postoperative clients.
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what type of dietary plan does the nurse expect? 1. Low in fat 2. High in iron 3. High in fluids 4. Low in residue
Answer: 3. High in fluids Reason: A common side effect of vincristine is a paralytic ileus, which results in constipation. Preventative measures include high fiber foods and fluids that exceed minimum requirements. These will keep the stool bulky and soft, thereby promoting evacuation. Low fat, high in iron, and low in residue dietary plans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine.
Which drug requires the nurse to monitor the client for signs of hyperkalemia? 1. Furosemide (Lasix) 2. Metolazone (Zaroxolyn) 3. Spironolactone (Aldactone) 4. Hydrochlorothiazide (HydroDIURIL)
Answer: 3. Spironolactone (Aldactone) Reason: Spironolactone is a potassium-sparing diuretic; hyperkalemia is an adverse effect. Furosemide, metolazone, and hydrochlorothiazide generally cause hypokalemia.
A nurse is providing care to a client eight hours after the client had surgery to correct an upper urinary tract obstruction. Which assessment finding should the nurse report to the charge nurse or surgeon? 1. Incisional pain 2. Absent bowel sounds 3. Urine output of 20 mL/hour 4. Serosanguineous drainage on the dressing
Answer: 3. Urine output of 20 mL/hour Reason: A urinary output of 50 mL/hr or greater is necessary to prevent stasis and consequent infections after this type of surgery. The nurse should notify the surgeon of the assessment findings, as this may indicate a urinary tract obstruction. Incisional pain, absent bowel sounds, and serosanguineous drainage are acceptable assessment findings for this client after this procedure and require continued monitoring but do not necessarily require reporting to the surgeon.
The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: 1. A physiological response to stress. 2. A conscious defense against anxiety. 3. An intentional attempt to gain attention. 4. An unconscious means of reducing stress
Answer: 4. An unconscious means of reducing stress Reason: When emotional stress overwhelms an individual's ability to cope, the unconscious seeks to reduce stress. A conversion reaction removes the client from the stressful situation, and the conversion reaction's physical/sensory manifestation causes little or no anxiety in the individual. This lack of concern is called la belle indifference. No physiological changes are involved with this unconscious resolution of a conflict. The conversion of anxiety to physical symptoms operates on an unconscious level.
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? 1. Oral psyllium (Metamucil) 2. Oral potassium supplement 3. Parenteral half normal saline 4. Parenteral albumin (Albuminar)
Answer: 4. Parenteral albumin (Albuminar) Reason: Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oral psyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplement is appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration.
The nurse is providing information about blood pressure to Unlicensed Assistive Personnel (UAP) and recalls that the factor that has the greatest influence on diastolic blood pressure is: 1. Renal function 2. Cardiac output 3. Oxygen saturation 4. Peripheral vascular resistance
Answer: 4. Peripheral vascular resistance Reason: Peripheral vascular resistance is the impedance of blood flow, or back pressure, by the arterioles, which is the most influential component of diastolic blood pressure. Renal function through the renin-angiotensin-aldosterone system regulates fluid balance and does influence blood pressure. Cardiac output is the determinant of systolic blood pressure. Oxygen saturation does not have a direct effect on diastolic blood pressure.