PN Fundamental v2 hesi

A LPN is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure?

Surgical asepsis

A LPN/LVN cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma?

Crush injury

What should the LPN/LVN consider when obtaining an informed consent from a 17-year-old adolescent?

If the client is allowed to give consent

A client asks about the purpose of a pulse oximeter. The LPN/LVN explains that it is used to measure the:

Percentage of hemoglobin-carrying oxygen

The LPN/LVN expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply

flushed face and increase pluse rate

A nurse receives a subpoena in a court case involving a child. The nurse is preparing to appear in court. In addition to the state Nurse Practice Act and the American Nursing Association (ANA) Code for Nurses, what else should the nurse review?

ANA Standards of Clinical Nursing Practice

A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the LPN/LVN primarily use nonverbal interventions?

Acceptance

The LPN/LVN is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply

Allergy to the medication Drainage from the ear canal Tympanic membrane rupture

A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take? A Ask the client if he is okay.

Ask security to make sure the room is safe

A LPN/LVN is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply.

Ask the client what is the client's acceptable level of pain. Administer the pain medications regularly around the clock

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the LPN must consider? Select all that apply

Assessment of skin turgor Administration of antiemetic drugs Replacement of fluid and electrolytes

Which nursing activities are examples of primary prevention? Select all that apply.

Assisting with immunization program Stopping smoking

The LPN/LVN recognizes that which are important components of a neurovascular assessment? Select all that apply.

B Capillary refill E Pulse and skin temperature F Movement and sensation

A LPN discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self- help groups such as AA meet to be successful?

Belonging

The LPN/LVN should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may:

Cause the device to pull away from the skin

A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the LPN/LVN should do when caring for this client is to:

Collect a sputum specimen

A client has been diagnosed as brain dead. The LPN/LVN understands that this means that the client has

Deep tendon reflexes only and no independent breathing

What clinical indicators should the LPN/LVN expect a client with hyperkalemia to exhibit? Select all that apply

Diarrhea Weakness Dysrhythmias

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply

Diminished sensation of pain Impaired hearing of high-frequency sounds

What type of interview is most appropriate when a LPN/LVN admits a client to a clinic?

Directive

A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication?

Drinking alcohol daily can cause drug-induced hepatitis

Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include?

Encouraging daily physical exercise

The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The LPN should monitor for what complication associated with this type of surgery?

Expectoration of blood

When being interviewed for a position as a registered professional LPN, the applicant is asked to identify an example of an intentional tort. What is the appropriate response?

False imprisonment

Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her health care provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action?

Give the infant to the client and instruct her regarding the infant's care.

The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the LPN/LVN take?

Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought

A LPN is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider?

Globulin

To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the LPN/LVN expect the dietary plan to include?

High in fluids

Which age-related change should the LPN/LVN consider when formulating a plan of care for an older adult? Select all that apply

Increased sensitivity to glare Diminished sensation of pain

A LPN is reviewing studies to answer a clinical question as part of an evidence-based practice project. The study design determines the level of evidence. Place each methodology in order from the most reliable to the least reliable

Meta-analysis

A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the LPN/LVN monitor this client?

Metabolic acidosis

A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the LPN/LVN best handle this situation?

Move the neighboring client to a room at the end of the hall

Place each step of the nursing process in the order that it should be used.

Obtain client's nursing history. Correct State client's nursing needs. Correct Identify goals for care. Correct Develop a plan of care. Correct Implement nursing interventions.

The triage LPN in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last?

Older adult male with a partially amputated finger

Client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the LPN emphasize when informing the client about exposure to radiation?

Only a small part of the body is irradiated

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 LPN/LVN question

Parenteral albumin (Albuminar)

Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply

Prayer Hypnosis Aromatherapy Guided imagery

When a client files a lawsuit against a LPN for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as:

Proximate cause

In what position should the LPN/LVN place a client recovering from general anesthesia?

Side-lying

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the LPN consider about how gamma globulin provides passive immunity?

The antigen is neutralized by the antibodies that it supplies

A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the LPN puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted?

The child had a right to remain in the room with the other children

During the initial physical assessment of a newly admitted client with a pressure ulcer, a LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?

The nurse provided supportive nursing care for the well-being of the client.

Following a surgery on the neck, the client asks the LPN why the head of the bed is up so high. The LPN should tell the client that the high-Fowler position is preferred for what reason?

To reduce edema at the operative site

A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the LPN monitor the client? Select all that apply.

Tremors and palpations

A LPN/LVN who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response by the LPN/LVN?

We have no record of that client on our unit. Thank you for calling."

A LPN is teaching an adolescent about type 1 diabetes and self- care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply

what is diabetes and can you tell me how to use the glucose meter

A client reaches the point of acceptance during the stages of dying. What response should the LPN/LVN expect the client to exhibit?

Detachment

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the LPN should change the administration set every

72 to 96 hours

A LPN is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply.

A Clean the eyelid and eyelashes. . C Apply clean gloves before beginning of procedure. E Press on the nasolacrimal duct after instilling the solution.

A LPN/LVN is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include:

An increase in body warmth and some swallowing difficulties if it has a better choice pls select

The LPN/LVN plans care for a client with a somatoform disorder based on the understanding that the disorder is:

An unconscious means of reducing stress

The LPN is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication?

Contact the primary health care provider and discuss the possibility of simplifying the medication regimen

A client reports fatigue and dyspnea and appears pale. The LPN/ LVN questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned?

Methyldopa (Aldomet)

The LPN/LVN assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is:

normal.