HESI PREP
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? A Oral psyllium (Metamucil) B Oral potassium supplement C Parenteral half normal saline D Parenteral albumin (Albuminar)
D
A nurse obtains a prescription for wrist restraints for a client who is trying to pull out his NG Tube. Which of the following actions should the nurse take? a. Remove the restraints every 4 hr. b. Attach the restraints securely to the side of the client's bed. c. Apply the restraints to allow as little movement as possible. d. Allow room for two fingers to fit between the client's skin and the restraints.
D
The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift.
A
To ensure client safety a nurse manager is planning to observe a newly licensed nurse perform a straight catheterization on a client. In which of the following roles is a nurse manager functioning? a. Case manager b. Client educator c. Client advocate
A
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? A Give the infant to the client and instruct her regarding the infant's care. B Explain to the client that she can leave, but her infant must remain in the hospital. C Emphasize to the client that the infant is a minor and legally must remain until prescriptions are received. D Tell the client that hospital policy prevents the staff from releasing the infant until ready for discharge
A
What should the LPN/LVN consider when obtaining an informed consent from a 17-year-old adolescent? A If the client is allowed to give consent B The client cannot make informed decisions about health care. C If the client is permitted to give voluntary consent when parents are not available D The client probably will be unable to choose between alternatives when asked to consent
A
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A. Record the amount on the client's fluid output record. B. Encourage the client to increase oral fluid intake. C. Notify the health care provider of the findings. D. Palpate the client's bladder for distention.
A
Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back.
A B
Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? A Encouraging daily physical exercise B Performing yearly physical examinations C Providing hypertension screening programs D Teaching a person with diabetes how to prevent complications
A
In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels.
A
In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible? A. Daily black, sticky stool B. Daily dark brown stool C. Firm brown stool every other day D. Soft light brown stool twice a day
A
The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level
A
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the health care provider.
A
While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult."
A
Place each step of the nursing process in the order that it should be used. - state client's nursing needs - implement nursing interventions - obtain client's nursing history - identify goals for care - develop a plan of care
A Obtain client's nursing history. B State client's nursing needs. C Identify goals for care. D Develop a plan of care. E Implement nursing interventions
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide? A. Decrease intake of fluids after the evening meal. B. Drink a glass of cranberry juice every day. C. Drink a glass of warm decaffeinated beverage at bedtime. D. Consult the health care provider about a sleeping pill.
A
What type of interview is most appropriate when a LPN/LVN admits a client to a clinic? A Directive B Exploratory C Problem solving D Information giving
A
Which client is most likely to be at risk for spiritual distress? A. Roman Catholic woman considering an abortion B. Jewish man considering hospice care for his wife C. Seventh-Day Adventist who needs a blood transfusion D. Muslim man who needs a total knee replacement
A
Which nonverbal action should the nurse implement to demonstrate active listening? A. Sit facing the client. B. Cross arms and legs. C. Avoid eye contact. D. Lean back in the chair
A
While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A. Encourage the client to see the clinic's grief counselor. B. Determine if the client has a family history of suicide attempts. C. Inquire about whether the life partner was suffering from AIDS. D. Consult with the health care provider about the client's need for antidepressant medications.
A
A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment? A. Notify the friend that all medical information will be kept confidential. B. Explain the relationship to the charge nurse and ask for reassignment. C. Approach the client and ask if the assignment is uncomfortable. D. Accept the assignment but protect the client's confidentiality.
B
A nurse is caring for a client who has right-sided paralysis following a cerebrovascular accident. which of the following prescriptions should the nurse anticipate to prevent a plantar flexion contracture of the affected extremity? a. Ankle-foot orthotic b. Continuous passive motion machine c. Abduction splint d. Sequential compression device
B
A nurse is caring for a client who is grieving the loss of her partner. The client states I don't see the point of living anymore. which of the following actions should the nurse take? a. Request the client's family to provide additional support. b. Ask the client if she plans to harm herself. c. Tell the client that this is a normal response to grief. d. Recommend that the client seek spiritual guidance.
B
A nurse is caring for clients who are prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication? a. "I will first dissolve the tablet in water." b. "I will insert the tablet between my cheek and teeth." c. "I will place the tablet under my tongue." d. "I will chew the tablet."
B
A nurse is conducting a Weber test on a client. Which of the following is an appropriate action for the nurse to take? a. Deliver a series of high-pitched sounds at random intervals. b. Place an activated tuning fork in the middle of the client's forehead. c. Hold and activated tuning fork against the client's mastoid process. d. Whisper a series of words softly into one ear.
B
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines? A. Americans with Disabilities Act of 1990 B. ANA Code of Ethics with Interpretative Statements C. ANA's Scope and Standards of Nursing Practice D. Patient's Bill of Rights of 1990
C
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: A faint, barely detectable. B slightly weak, palpable. C normal. D bounding.
C
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? A Low in fat B High in iron C High in fluids D Low in residue
C
The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take? A. Consult with the pharmacist about the need to continue the medication. B. Administer the antihypertensive medication as prescribed preoperatively. C. Withhold the medication until the client is fully alert and vital signs are stable. D. Contact the health care provider to renew the prescription for the medication.
D
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? A Institute the prescribed blood transfusion because the client's survival depends on volume replacement. B Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. C Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. D Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought
D
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? A Negligence B Malpractice C Breach of duty D False imprisonment
D
When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to draw up the labeled saline solution. C. Use the saline solution and then relabel the bottle with the current date. D. Discard the saline solution and obtain a new unopened bottle.
D
A nurse is receiving the prescription for a client who is experiencing dysphagia following a stroke. Which of the following prescriptions should the nurse clarify? a. Dietitian consult b. Speech therapy referral c. Oral suction at the bedside d. Clear liquids
D Rationale: food levels for dysphagia include pureed, mechanically altered, advanced/mechanically soft, and regular.
A nurse is caring for a client who had a stroke and requires assistance with morning ADLs. Which of the following interprofessional team members should the nurse consult? a. Registered dietician- helps with healthy food planning. b. Occupational therapist c. Speech d. Physical therapist
B
A nurse is caring for a client who has a new diagnosis of terminal cancer. Which of the following interventions is a priority? a. Teach the client to use progressive relaxation techniques. b. Help the client to find a local support group. c. Discuss the client's prior coping mechanism. d. Develop a list of goals with the client.
C
A nurse overhears a colleague informing a client that he will administer her medication by injection if she refuses to swallow her pills. The nurse should recognize that the colleague is committing which of the following torts? a.) Defamation b.) Malpractice c.) Assault d.) Battery
C
The triage LPN in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? A Multipara in active labor B Middle-aged woman with substernal chest pain C Older adult male with a partially amputated finger D Adolescent boy with an oxygen saturation of 91%
C
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement? A. Assist the client to walk to the bathroom and do not leave the client alone. B. Request that the UAP assist the client onto a bedpan. C. Ask if the client needs to have a bowel movement or void. D. Assess the client's bladder to determine if the client needs to urinate.
A
Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers.
A
The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A. Stay with the client while the client is standing. B. Record the findings on the graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm. D. Record changes in the client's pulse rate.
A
A LPN is teaching an adolescent about type 1 diabetes and selfcare. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. A "What is diabetes?" B "What will my friends think?" C "How do I give myself an injection?" D "Can you tell me how the glucose monitor works?" E "How do I get the insulin from the vial into the syringe?
A D
A nurse is auscultating a client's abdomen. The nurse hears a blowing sound over the aorta. The nurse should identify this sound as which of the following? a. Gallop b. Bruit c. Thrill d. Murmur
B
A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse place the client for postural drainage? a. Supine and low-Fowler's position b. Right lateral in Trendelenburg position c. Side-lying with the right side of the chest elevated d. Prone with pillows under the extremities
B
A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely increase the client‟s motivation to learn? a. The nurse empathy about the client having to self-inject b. The client's belief that his needs will be met through education c. The client seeking family approval by agreeing to a teaching plan d. The nurse explaining the need for education to the client
B
The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure? A. Dilute each of the medications with sterile water prior to administration. B. Mix the medications in one syringe before opening the feeding tube. C. Administer water between the doses of the two liquid medications. D. Withdraw any fluid from the tube before instilling each medication.
C
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? A Occipital headache B Periorbital crepitus C Expectoration of blood D Changes in vocalization
C
The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents.
C
A nurse is inserting an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse take to verify proper placement of the tube? a. Place the end of the NG tube in water to observe for bubbling. b. Auscultate 2.5 cm (1 in) above the umbilicus while injecting 15 mL of sterile water. c. Assess the client's gag reflex. d. Measure the pH of the gastric aspirate.
D
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the LPN should change the administration set every: A 4 to 8 hours B 12 to 24 hours C 24 to 48 hours D 72 to 96 hours
D
A nurse in an emergency department is assessing a client who reports RIGHT lower quadrant pain, nausea and vomiting for the past 48 hr. Which of the following actions should the nurse take first? a. Auscultate bowel sounds. b. Administer an antiemetic. c. Offer a pain med. d. Palpate the abdomen.
A
A nurse is assisting in the use of a fracture bedpan for a client who is immobile due to a cast. Which of the following actions should the nurse take? a. Place the shallow end of the fracture pan under the client's buttocks. b. Hyperextend the client's back while the fracture pan is in place. c. Keep the bed flat while the client is on the fracture pan d. Encourage the client to try to defecate for 20 min while on the fracture pan.
A
A nurse is caring for a client who has extracellular fluid volume deficit. Which of the following findings should the nurse expect? a. Postural hypotension b. Distended neck veins c. Dependent edema d. Bradycardia
A
A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first? a. Peripheral pulses b. Comfort level c. Elimination needs d. Skin integrity
A
A home health nurse is teaching a new caregiver how to care for a client who has had a tracheostomy for 1 year. Which of the following instructions should the nurse include? a. "Use tracheostomy covers when going outdoors." b. "Maintain sterile technique when performing tracheostomy care." c. "Remove the outer cannula for routine cleaning." d. "Clean around the stoma with povidone-iodine."
B
A nurse is assessing a client‟s extraocular eye movements. Which of the following should the nurse take? a. Instruct the clients to follow a finger through the six cardinal fields of gaze. b. Hold a finger 46 cm (18 in) in front of the client‟s eyes. c. Ask the clients to cover her right eye during assessment of her left eye. d. Position the client‟s 6.1 m (20 feet) away from the Snellen chart. (This is for cranial nerve 2)
A Rationale: Cardinal fields of gaze test for cranial nerves 3, 4, and 6 which are for eye movement
A nurse is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care? a. Blood glucose 45 mg/dL b. Blood pressure 148/92 mm Hg c. Body mass index 28 kg/m2 d. Heart rate 105/min
A Rationale: low/hypoglycemia may lead to shock level is abnormally low, [74-106 mmol/L]
A nurse is caring for a client who has TB. Which of the following precautions should the nurse plan to implement when working with the client? a. Airborne b. Droplet c. Protective d. Contact
A Rationale: measle, varicella, pulmonary or laryngeal tuberculosis
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. Take a vitamin supplement tablet once a day. B. Change positions in the chair at least every hour. C. Increase daily intake of water or other oral fluids. D. Purchase a newer model wheelchair.
B
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? A Albumin B Globulin C Thrombin D Hemoglobin
B
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? A Famotidine (Pepcid) B Methyldopa (Aldomet) C Ferrous sulfate (Feosol) D Levothyroxine (Synthroid)
B
In what position should the LPN/LVN place a client recovering from general anesthesia? A Supine B Side-lying C High Fowler E Trendelenburg
B
When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward, underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.
B
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? A Trust B Growth C Belonging D Independence
C
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? A Droplet precautions B Reverse isolation C Surgical asepsis D Medical asepsis
C
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? A Abrasion B Fracture C Crush injury D Incisional laceration
C
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: A A loss of skin elasticity and a decrease in libido B Impaired fat digestion and increased salivary secretions C Increased blood pressure and decreased hormone production D An increase in body warmth and some swallowing difficulties
C
A client asks about the purpose of a pulse oximeter. The LPN/LVN explains that it is used to measure the: A Respiratory rate. B Amount of oxygen in the blood. C Percentage of hemoglobin-carrying oxygen. D Amount of carbon dioxide in the blood
C
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: A Encourage fluids. B Administer oxygen. C Take the temperature. D Collect a sputum specimen
C
When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take? A. Deflate the cuff completely and immediately reattempt the reading. B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading. C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
C
Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis? A. Perform cough and deep breathing exercises hourly. B. Turn from side to side in bed at least every 2 hours. C. Dorsiflex and plantarflex the feet 10 times each hour. D. Drink approximately 4 ounces of water every hour.
C
Which age-related change should the LPN/LVN consider when formulating a plan of care for an older adult? Select all that apply. A Difficulty in swallowing B Increased sensitivity to heat C Increased sensitivity to glare D Diminished sensation of pain E Heightened response to stimuli
C D
A nurse is changing a client's colostomy pouch and notices peristomal skin irritation. Which of the following actions should the nurse take? a. Change the pouch once every 24 hour. b. Apply the pouch while the skin Barrier is still damp. c. Rub the peristomal skin dry after cleaning. d. Ensure the pouch is 0.32 cm (1/8 in) larger than the stoma.
D
A nurse is caring for a client who has left lower atelectasis. In which of the following positions should the nurse place the client for postural drainage? e. Supine and low-Fowler's position f. Right lateral in Trendelenburg position g. Side-lying with the right side of the chest elevated h. Prone with pillows under the extremities
F
A nurse is providing teaching to a client who had a new medication prescription. Which of the following manifestations of a mild allergic reaction should the nurse include? a. Urticaria (itchy, red welts) b. Ptosis (upper eyelid droop) c. Nausea d. Hematuria (blood in urine)
A
A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury
A
A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessments findings should the nurse identify as a contraindication to the application of cold? a. Cap refill 4 seconds b. 7.5 cm (3 in) diameter bruise on the ankle c. Warts on the affected ankle d. 2+ pitting edema
A
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A. Mode of transmission B. Portal of entry C. Reservoir D. Portal of exit
A
During an admission history a client tells a nurse that she is under a lot of stress. Which of the following physiological responses should the nurse expect to increase as a result of stress? a. Blood glucose b. Intestinal peristalsis c. Peripheral blood vessels diameter d. Urine output
A
A nurse is administering a large volume enema to a client. Identify the sequence of steps the nurse should follow after preparation and lubricating the enema set. 1. Administer the enema solution. 2. Remove the enema tube from the client's rectum. 3. Wrap the end of the enema tube with disposable tissue. 4. Insert the enema tube into the client's rectum. 5. Clamp the enema tube.
4 1 5 2 3
A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take? a. Apply the cuff above the client's antecubital fossa. b. Use a cuff with a width that is about 60% of the client's arm circumference. c. How the clients sit with his arm resting above the level of his heart. d. Release the pressure on the client's arm 5 to 6 mm per second.
A
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? A "We have no record of that client on our unit. Thank you for calling." B "The new privacy laws prevent me from providing any client information over the phone." C "The client has requested that no information be given out. You'll need to call the client directly." D "It is against the hospital's policy to provide you with any information regarding any of our clients."
A
A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best? A. Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows. B. Instruct the UAP not to wake the client under any circumstances during the night. C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8 hours. D. Encourage the client to avoid pain medication during the day, which might increase daytime napping.
A
A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond? A. Ask him to rate his pain on a scale of 1 to 10. B. Encourage him to wait until bedtime so the pill can help him sleep. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct him in the use of deep breathing exercises for pain control.
A
A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The stop should include that the nurse signature on the form confirms which of the following requirements? (Select all that apply.) a. The client was not coerced. b. The client does not have a mental health condition. c. The client Signed in the nurse‟s presence. d. The client speaks the same language as the nurse. e. The client has the legal authority to do so.
A B C E
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. A Prayer B Hypnosis C Medication D Aromatherapy E Guided imagery
A B D E
A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the LPN monitor the client? Select all that apply. A Tremors B Lethargy C Palpitations D Visual disturbances E Decreased pulse rate
A C
An 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. A Ask the client what is the client's acceptable level of pain. B Eliminate all activities that precipitate the pain. C Administer the pain medications regularly around the clock. D Use a different pain scale each time to promote patient education. E Assess the client's pain every 15 minutes
A C
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. A Allergy to the medication B Itching in the ear canal C Drainage from the ear canal D Tympanic membrane rupture E Partial hearing loss in the affected ear
A C D
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. B Place the dropper against the eyelid. C Apply clean gloves before beginning of procedure. D Instill the solution directly onto cornea. E Press on the nasolacrimal duct after instilling the solution.
A C E
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A. Place the client in a high Fowler position. B. Help the client assume a left side-lying position. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx.
A D
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. A Assessment of skin turgor B Documentation of vital signs C Assessment of intake and output D Administration of antiemetic drugs E Replacement of fluid and electrolytes
A D E
A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client at risk for poor wound healing? a. Serum albumin 3 g/dL b. Total lymphocyte count 2400 mm3 c. HCT 42% d. HGB 16g/dL
A Rationale: Albumin is low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the client at risk for poor wound healing. The other lab values are within normal limits.
A nurse is teaching a client who has diabetes mellitus about mixing regular and NPH insulin. Which of the following statements by the client indicates an understanding of the teaching? a. "I should roll the NPH between my hands before drawing it up." b. "I should wait 10 minutes after mixing the insulin to inject it. c. "I should draw up the NPH insulin before the regular insulin." d. "I should inject air into the vial of regular insulin first."
A Rationale: must ROLL not shake
A nurse is caring from a client who has a tracheostomy. Which of the following actions should the nurse take? a. Clean the skin around the stoma with normal saline. b. Secure the tracheostomy ties with one finger to fit snugly underneath. c. Soak the outer cannula in warm tap water. d. Use a cotton tip applicator to clean the inside in the inner cannula.
A Rationale: using NS-saturated cotton-tipped sterile swabs and 4x4 gauze, clean exposed outer cannula surfaces and soma under faceplate, extending 5-10cm (2-4in) in all directions from stoma.
A nurse in the emergency department is measuring a client‟s oral temperature using an electronic thermometer. Which of the following actions should the nurse take? a. Provide oral hygiene prior to measuring the client‟s temperature. b. Ask the client if he has smoked within the past 30 min c. Attach the red tip probe to the thermometer unit. d. Place the tip of the probe along the client‟s buccal mucosa.
B
A nurse is caring for a client who has a chest tube following thoracic surgery. Which of the following tasks should the nurse delegate to an assistive personnel? a. Teach deep breathing and coughing to the client. b. Assist the client to select food choices from the menu. c. Evaluate the client‟s response to pain medication. d. Monitor the characteristics of the client's chest tube drainage.
B
A nurse is caring for a client who is on bed rest following an abdominal surgery. Which of the following findings indicates the need to increase the frequency of position changes? a. Flat rash on the client's ankle b. Non blanching red area over my clients trochanter c. Ecchymosis on the clients left shoulder d. Petechiae on the client's right anterior thigh
B
A nurse is caring for a client who reports that she has insomnia. Which of the following interventions is appropriate for the nurse to recommend? a. Exercise 1 hr before bedtime. b. Eat a light carbohydrate snack before bedtime. c. Drink a cup of hot cocoa before bedtime. d. Take a 30 min nap daily.
B
A nurse is documenting client care. Which of the following abbreviations should the nurse use? a. "SS" for sliding scale b. "BRP" for bathroom privileges c. "OJ" for orange juice d. "SQ" for subcutaneous
B
A nurse is providing care for a client who is to undergo total laryngectomy. which of the following interventions is the nurse‟s priority? a. Schedule a support session for the client. b. Explain the techniques of esophageal speech. c. Review the use of artificial larynx with the client. d. Determine the client's reading ability.
B
A seriously ill female client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about her feelings related to her own death. C. Collaborate with the health care provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local health care facility.
B
A staff nurse is teaching a newly hired nurse about alternatives to the use of restraints on clients who are confused. Which of the following instructions should the nurse include? a. "Use full-length side rails on the client‟s bed." b. "Check on the client frequently while he is in the restroom." c. "Encourage physical activity throughout the day to expand energy." d. "Remove clocks from the client‟s room."
B
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? A Limits had to be set to control the child's crying. B The child had a right to remain in the room with the other children. C The child had to be removed because the other children needed to be considered. D Segregation of the child for more than half an hour was too long a period of time
B
After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse implement? A. Complete an incident report. B. Select another sterile needle. C. Disinfect the needle with an alcohol swab. D. Notify the supervisor of the department immediately.
B
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? A The dosage is kept at a minimum. B Only a small part of the body is irradiated. C The client's physical condition is not a risk factor. D Nutritional environment of the affected cells is a risk factor
B
During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A. Assign an unlicensed assistive personnel to transport the client via a wheelchair. B. Remind the client to walk carefully down the stairs until reaching a lower floor. C. Ask the client to help by assisting a wheelchair bound client to a nearby elevator. D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly.
B
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? A The nurse also should have instituted a plan to increase activity. B The nurse provided supportive nursing care for the well-being of the client. C Debridement of the pressure ulcer should have been done before the dressing was applied. D Treatment should not have been instituted until the health care provider's prescriptions were received.
B
Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit.
B
The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication? A. The client will experience increased tolerance to the drug's effects and may need a higher dose. B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect. C. The medication will be more highly protein-bound, increasing the duration of action. D. The therapeutic index will be increased, placing the client at greater risk for toxicity.
B
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A. Apply a warm compress proximal to the site. B. Check for kinks in the tubing and raise the IV pole. C. Adjust the tape that stabilizes the needle. D. Flush with normal saline and recount the drop rate.
B
The nurse identifies a potential for infection in a client with partialthickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful handwashing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns
B
The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months
B
The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? A. 14 B. 16 C. 17 D. 28
B
The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then compress the inhaler." B. "Compress the inhaler while slowly breathing in through your mouth." C. "Compress the inhaler while inhaling quickly through your nose." D. "Exhale completely after compressing the inhaler and then inhale."
B
The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad B. Broiled fish, green beans, and an apple C. Pork chops, macaroni and cheese, and grapes D. Avocado salad, milk, and angel food cake
B
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
B
The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A. Left brachial vein B. Right cephalic vein C. Dorsal side of the right wrist D. Right upper extremity
B
The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly? A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt.
B
When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly.
B
Which action should the nurse implement when providing wound care instructions to a client who does not speak English? A. Ask an interpreter to provide wound care instructions. B. Speak directly to the client, with an interpreter translating. C. Request the accompanying family member to translate. D. Instruct a bilingual employee to read the instructions.
B
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. A Difficulty in swallowing B Diminished sensation of pain C Heightened response to stimuli D Impaired hearing of high-frequency sounds E Increased ability to tolerate environmental heat
B D
The LPN/LVN expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. A Dyspnea B Flushed face C Precordial pain D Increased pulse rate E Increased blood pressure
B D
The LPN/LVN recognizes that which are important components of a neurovascular assessment? Select all that apply. A Orientation B Capillary refill C Pupillary response D Respiratory rate E Pulse and skin temperature F Movement and sensation
B E F
A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump. Which of the following actions should the nurse take first? a. Label the pump with a defective equipment sticker. b. Unplug the pump. c. Obtain a replacement pump. d. Notified the biomedical department to fix the pump.
B Rationale: Prioritization question. YOU WILL FIRST UNPLUG the IV pump to avoid causing a fire.
A nurse is teaching a group of newly licensed nurses about the Braden Scale. Which of the following responses by the newly licensed nurse indicates an understanding of the teaching? a. "The client‟s age is part of the measurement." b. "The scale measures six elements." c. "The higher the score, the higher the pressure ulcer risk." d. "Each element has a range from 1 to 5 points."
B Rationale: The six elements are 1. Sensory Perception, 2. Moisture, 4. activity, 5. mobility ,6. nutrition , 7. friction and shear.
A nurse is performing a dressing change on a client and observes granulation tissue. Which of the following findings should the nurse document? a. Stringy, white tissue b. Translucent, red tissue c. Soft, yellow tissue d. Thick, black tissue
B red means healthy and it's healing
A client reaches the point of acceptance during the stages of dying. What response should the LPN/LVN expect the client to exhibit? A Apathy B Euphoria C Detachment D Emotionalism
C
A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first? A. Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the health care provider and request a prescription for a large-volume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids top five 8-ounce glasses per day.
C
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? A Curling ulcer B Renal shutdown C Metabolic acidosis D Hemolysis of red blood cells
C
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? A. Orange juice has vitamin C that deters bacterial growth. B. Apple juice is the most useful in acidifying the urine. C. Cranberry juice stops pathogens' adherence to the bladder. D. Grapefruit juice increases absorption of most antibiotics.
C
A nurse is assessing a client's ability to balance. Which of the following actions is appropriate when the nurse conducts a Romberg test? a. Ask the client to extend her arms in front of her body. b. Ask the client to walk in a straight line heel To toe. c. Have the client stand with her feet together. d. How the client place her hands on her hips.
C
A nurse is collecting a blood pressure reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mmHg. Which of the following actions should the nurse take? a. Ensure that the width of the BP cuff is 50% of the client's upper arm circumference. b. Reposition the client supine and recheck her BP. c. Recheck the client's BP in her other arm for comparison. d. Request that another nurse checks the client's BP in 30 minutes.
C
A nurse is performing an admission assessment of a client. Which of the following actions should the nurse take when recording the client's medication? a. Council the client about medication adherence. b. Assess the client for medication reactions. c. Compile a list of the client's current medications. d. Evaluate the client's understanding of medications.
C
A nurse is planning to use nonpharmacological pain methods for a client who reports still having mild back pain after receiving analgesia 1 hour ago. Which of the following actions should the nurse include in the plan? a. Apply an ice pack to the client's back for 1 hr b. Remove distractions from the client‟s room. c. Instruct the client to take deep rhythmic breaths. d. Encourage the client to apply a heating pad for 2 hr at a time.
C
A nurse is providing discharge teaching about safety considerations to an older adult client who lives at home. The client has heart failure and a new prescription for hydrochlorothiazide. Which of the following statements by the client indicates an understanding of the teaching? a. "I will take a hot bath before going to bed." b. "I will take my new medication in the evening." c. "I will leave a light on in my bathroom at night." d. "I will weigh myself once weekly."
C
A nurse on a medical-surgical unit is dividing care for four clients. The nurse should identify which of the following situations as an ethical dilemma? a. A client who has a new colostomy refuses to take instructions from the ostomy therapist because she "doesn't like him." b. A surgeon who removed the wrong kidney during a surgical procedure refuses to take responsibility for her actions. c. The family of a client who has a terminal illness asks the provider not to tell the client the diagnosis. d. A client who has Crohn's disease reports that his prescription drug plan will not pay for his medications.
C
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? A Nursing's Social Policy Statement B State law regarding protection of minors C ANA Standards of Clinical Nursing Practice D References regarding a child's right to consent
C
A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit? A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked. C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.
C
After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond? A. Ask the client to remain quiet so the procedure can be performed safely. B. Concentrate on completing the insertion as efficiently as possible. C. Calmly reassure the client that the discomfort will be temporary. D. Tell the client a joke as a means of distraction from the procedure.
C
An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections? A. "I know you are capable of giving yourself the insulin." B. "Giving yourself the injection seems to make you nervous." C. "When I watched you give yourself the injection, you did it correctly." D. "Tell me what you want me to do to help you give yourself the injection at home."
C
In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A. Witness the client's signature to the permit. B. Answer the client's questions about the surgery. C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.
C
One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond? A. "You may not have enough energy before long to hold a big party." B. "Do you mean to say that you want to plan your funeral and wake?" C. "Planning a party and thinking about all your friends sounds like fun." D. "You should be thinking about spending your last days with your family."
C
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? A Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. B Develop a chart for the client, listing the times the medication should be taken. C Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. D Instruct the client and client's children to put medications in a weekly pill organizer
C
The LPN/LVN should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: A Force urine to back up into the kidneys. B Suppress production of urine. C Cause the device to pull away from the skin. D Tear the ileal conduit
C
The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You"
C
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction.
C
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: A Evidence B Tort discovery C Proximate cause D Common cause
C
When bathing an uncircumcised boy older than 3 years, which action should the nurse take? A. Remind the child to clean his genital area. B. Defer perineal care because of the child's age. C. Retract the foreskin gently to cleanse the penis. D. Ask the parents why the child is not circumcised.
C
What clinical indicators should the LPN/LVN expect a client with hyperkalemia to exhibit? Select all that apply. A Tetany B Seizures C Diarrhea D Weakness E Dysrhythmias
C D E
A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse? a. "This test will indicate if you are at risk for developing blood clots b. "This test will determine if your heart is performing properly" c. "This test will provide information about the function of your liver" d. "This test is used to check how your kidneys are working"
C Rationale: ALT test measures amount of enzyme in blood. ALT mainly found in liver Rationale: ALT and AST measure you liver function. Creatinine and BUN measure your kidney function
A nurse is providing teaching about health promotion guidelines to a group of young adult male clients. Which of the following guidelines should the nurse include? a. "Obtain a tetanus booster every 5 years." b. "Obtain a herpes zoster immunization by age 50." c. "Have a dental examination every 6 months." d. "Have a testicular examination every 2 years."
C need dental exams bc they are prone to infection
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D. Teach the importance of personal hygiene during menstruation with the client.
D
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client.
D
A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first? A. Clamp the nasogastric tube. B. Confirm placement of the tube. C. Use a syringe to instill the medications. D. Turn off the intermittent suction device.
D
A client has been diagnosed as brain dead. The LPN/LVN understands that this means that the client has: A No spontaneous reflexes B Shallow and slow breathing C No cortical functioning with some reflex breathing D Deep tendon reflexes only and no independent breathing
D
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? A It increases production of short-lived antibodies. B It accelerates antigen-antibody union at the hepatic sites. C The lymphatic system is stimulated to produce antibodies. D The antigen is neutralized by the antibodies that it supplies
D
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings.
D
A community health nurse is caring for a group of families. The nurse should identify that which of the following families is experiencing a maturational loss? a. A family whose only child recently died due to cancer. b. A family whose head of household lost her job. c. A family whose house was destroyed in a fire. d. A family whose oldest child is moving away for college
D
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? A Anger B Denial C Bargaining D Acceptance
D
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication? A Prolonged use can cause dark concentrated urine. B The medication is best absorbed when taken on an empty stomach. C Take the medication with aluminum hydroxide to minimize GI upset. D Drinking alcohol daily can cause drug-induced hepatitis
D
A nurse at an assisted living facility is preparing an in-service for residents about electrical safety. Which of the following instructions should the nurse include? a. Avoid taping electrical cords to the floor. b. Clean electrical equipment prior to disconnection. c. Cover exposed wires with tape before used. d. Disconnect electrical equipment by grasping the plug.
D
A nurse is admitting a client who is malnourished. The client states my wedding ring is loose and I'm worried I will lose it if it falls off. Which of the following is an appropriate response by the nurse? a. "I can pin it to your hospital gown, so you won't lose it." b. "I will place it in your drawer, so it won't get lost." c. "I will hold onto it until a family member can take it home." d. "I can put it in a locked storage unit for you."
D
A nurse is assessing a client whose therapy has included bed rest for several weeks. Which of the following findings should the nurse identify as the priority? a. Musculoskeletal weakness b. Loss of appetite c. Increased heart rate during physical activity d. Left lower extremity tenderness
D
A nurse is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the nurse provide to the assistive personnel? a. Collect at least 2 inches of formed stool. b. Wear sterile gloves while obtaining the specimen. c. Use a culturette for specimen collection. d. Record the date and time the stool was collected.
D
A nurse is caring for a client who has a tracheostomy collar. As the nurse is performing tracheal suctioning, the client‟s heart rate and oxygen saturation decrease. Which of the following actions should the nurse take? a. Elevate the head of the bed. b. Remove the inner cannula. c. Irrigate the stoma. d. Discontinued suctioning.
D
A nurse is caring for a client who has chronic back pain and asked about receiving acupuncture for relief. Which of the following findings should the nurse identify as a contraindication to receiving this shipment? a. Obesity b. Hypertension c. Migraines d. Cellulitis
D
A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include? a. Monitor the client for pain in the suprapubic region. b. Ensure the client is free of metal objects. c. Administer 240 mL (8 oz) of oral contrast before the procedure. d. Assist the client with a bowel cleansing.
D
A nurse is preparing a change of shift report after the night shift using one SBAR communication tool. Which of the following data should the nurse include when reporting background information? a. "Blood pressure 160/92 mm Hg" b. "Start the first dose of penicillin at 1200" c. "Pain rating of 5 on a scale from 0 to 10" d. "Code status: do-not-resuscitate"
D
A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate action for the nurse to take? a. Hold the suction catheter with the clean non-dominant hand. b. Apply suctioning for 20 to 30 seconds. c. Place the catheter in a location that is clean and dry for later using new line. d. Use surgical asepsis when performing the procedure.
D
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? A Tell the neighboring client to stop singing. B Close the doors to both clients' rooms at night. C Give the complaining client the prescribed as needed sedative. D Move the neighboring client to a room at the end of the hall
D
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. B Call security from the room. C Find out if there is anyone else in the room. D Ask security to make sure the room is safe
D
After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of Internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C. Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or health care provider if any questions arise.
D
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report? A. The occurrence of any episodes of sleep apnea B. The child's blood pressure, pulse, and respirations C. Length of rapid eye movement (REM) sleep that the child is experiencing D. Description of the family's home environment
D
During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns.
D
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? A To avoid strain on the incision B To promote drainage of the wound C To provide stimulation for the client D To reduce edema at the operative site
D
The LPN/LVN plans care for a client with a somatoform disorder based on the understanding that the disorder is: A A physiological response to stress B A conscious defense against anxiety C An intentional attempt to gain attention D An unconscious means of reducing stress
D
The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A. Only refer to the client by gender. B. Identify the client only by age. C. Avoid using the client's name. D. Discuss the client another time.
D
The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement? A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea.
D
The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client. B. Sit quietly in the client's room until the client leaves the bathroom. C. Allow the client to cry alone and leave the client in the bathroom. D. Talk to the client and attempt to find out why the client is crying.
D
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A. "At home I take my pills at 8:00 am." B. "It costs a lot of money to buy all of these pills." C. "I get so tired of taking pills every day." D. "This is a new pill I have never taken before."
D
The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor.
D
The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A. Determine how the client feels about changing the dressing. B. Ask the client to describe the procedure in writing. C. Seek a family member's evaluation of the client's ability to change the dressing. D. Observe the client change the dressing unassisted.
D
The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine he is currently following.
D
When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she "can't handle" the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the son has the right to waive informed consent for her. C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence.
D
Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation? A. Instruct in the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D. Encourage frequent ambulation in the hallway.
D
Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?. A. Self-care deficit B. Functional incontinence C. Fluid volume deficit D. High risk for infection
D
Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium
D
Which nursing activities are examples of primary prevention? Select all that apply. A Preventing disabilities B Correcting dietary deficiencies C Establishing goals for rehabilitation D Assisting with immunization program E Stopping smoking
D E
A nurse is planning care for a client who has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care? a. Obtain a random blood glucose daily. b. Change the PN infusion bag every 48 hr. c. Prepare the client for a central venous line. d. Administer the PN and fat emulsion separately.
D Rationale: Administer separate IV line below the filter using a Y-connector or as a admixture to PN solution (3-in-1 admixture consisting dextrose, AA, and Lipids
A nurse is caring for a client who has a prescription for morphine 5mg IM accidentally administers the whole 10 mg from the single-dose vial. Which of the following actions should the nurse take first? a. Notify the client's provider. b. Report the incident to the pharmacy. c. Complete an incident report. d. Measure the client's respiratory rate
D Rationale: Morphine can cause respiratory depression if given too much. Also you should ALWAYS ASSESS the patient first when a med error is performed to make sure med error doesn't put the client‟s health in risk.