k pn 2018--4

The LPN/LVN assists in the care of a client in labor. The LPN/LVN is MOST concerned if which of the following is observed? 1. Late decelerations. 2. Early decelerations. 3. Irregular heart rate. 4. Variable decelerations.

Late decelerations. Strategy: Think about each answer. (1.) CORRECT— fall in fetal heart rate after the peak of the contraction; indicates fetal hypoxia; position client on her left side, administer oxygen by mask, start IV or increase flow rate, stop oxytocin if appropriate (2.) fall in fetal heart rate before the peak of the contraction; reassuring fetal heart tone pattern (3.) fetuses tend to have irregular heart rates (4.) occurs any time during the contraction; ominous if repetitive, prolonged, severe, or slow return to baseline

After the LPN/LVN completes the hospital health history form for a client suspected of having cirrhosis, the LPN/LVN posts which sign above the head of the client's bed? 1. "Seizure precautions." 2. "Do not raise head of bed." 3. "No IM injections." 4. "No blood pressures in left arm."

"No IM injections. Strategy: Think about the outcome of each answer. 1) clients with cirrhosis may have mental changes associated with increased serum ammonia (NH 3) levels, but risks of seizures are not as common as risk of excessive bleeding 2) more appropriate for clients with damaged or fractured spines 3) CORRECT — because the liver contributes to the production of clotting factors, clients with liver damage are more prone to bleeding; IM injections should be avoided to prevent excessive bruising or bleeding 4) more appropriate for postmastectomy clients

The LPN/LVN cares for a client diagnosed with ureterolithiasis. Which of the following actions should the LPN/LVN take FIRST? 1. Administer pain medication. 2. Provide device for straining urine. 3. Instruct client to drink 8 ounces of cranberry juice daily. 4. Place in high Fowler's position.

1. Administer pain medication. Strategy: "FIRST" indicates priority. (1.) CORRECT— clients usually experience severe pain; client comfort should take priority (2.) will need to strain urine to determine if stone has been expelled or to determine the contents of the stone (3.) more appropriate for UTI; microorganisms are less likely to grow in acidic solutions (4.) this position will not contribute to client comfort nor will it promote expulsion of the stone

A young adult with hemophilia bumps the knee and develops painful swelling of the knee. In providing care for the client, which action is the most appropriate for the LPN/LVN to take initially? 1. Apply ice to the injured knee and elevate the leg. 2. Prepare the client for blood administration. 3. Explain physical limitations to the client. 4. Administer analgesics for pain for 24 hours.

1. Apply ice to the injured knee and elevate the leg. Strategy: "Initially" indicates priority. 1) CORRECT — hemophilia is a sex-linked recessive trait transmitted to males by female carriers; deficiency of factor VIII; abnormal bleeding in response to trauma; signs include easy bruising, joint pain with bleeding, and prolonged internal or external bleeding; instruct client to institute supportive measures when trauma occurs — rest, ice, compression, and elevation (RICE); applying ice to his knee and elevating his leg is the most appropriate action to take initially because it will help to stop the bleeding and decrease the swelling; will also help to alleviate the pain 2) administering factor VIII cryoprecipitate is more appropriate; transfusions are more relevant after significant bleeding 3) most important to institute measures to prevent bleeding; assessment of how trauma occurred and how it can be prevented after bleeding is controlled 4) bleeding into joints and muscles can be painful; most important to control bleeding

The nurse cares for a client at 36 weeks gestation with a history of repeated spontaneous abortions. The client is admitted for an emergency appendectomy and is very upset because of fear of losing the baby. Which action by the LPN/LVN is most appropriate? 1. Encourage the client to listen to the fetal heart tone (FHTs). 2. Offer to call a close family member. 3. Offer to call the client's religious leader. 4. Hold the client's hand and offer words of encouragement and comfort

1. Encourage the client to listen to the fetal heart tone (FHTs). Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) CORRECT—primary fears are concerns about the health of the fetus; provides direct evidence of the current status of the fetus (2) although having a close family member near during a time of crisis can be helpful, assurance that the fetus is healthy is more likely to lower anxiety level (3) although clients often rely on spiritual guidance from their spiritual leaders during times of crisis, physical evidence of fetal well-being is likely to lower anxiety level; concrete evidence tends to be more effective when clients are anxious (4) probably is the second-best option; touch and comfort by another can be anxiety-relieving; should comfort client while she is listening to the FHTs

An older client reports urinary frequency, urgency, and dysuria to the health care provider. A cystoscopy is done. After the cystoscopy, which nursing action by the LPN/LVN has the highest priority? 1. Evaluate the client's vital signs. 2. Report any nausea to the health care provider. 3. Review the client's written discharge instructions. 4. Give the client sedation.

1. Evaluate the client's vital signs Strategy: Determine the outcome of each answer. (1) CORRECT—assess for bleeding and infection, which indicate complication; cystoscopy is direct visualization of the bladder; monitor character and volume of urine; urine usually pink-tinged; abnormal color and pelvic pain indicate trauma (2) notify the health care provider if there are blood clots or if the urinary output decreases (3) is appropriate but LPN/LVN should first assess before implementing (4) if cystoscopy is performed under local anesthesia, the client will be given sedation before the procedure

An older adult lives alone on a limited income. The client's diet consists primarily of carbohydrates. Which of the following actions by the LPN/LVN is MOST appropriate? 1. Instruct the client to increase intake of protein. 2. Instruct the client to reduce intake of fat. 3. Instruct the client to increase caloric intake. 4. Instruct the client to decrease fluid intake.

1. Instruct the client to increase intake of protein. Strategy: Topic of question is unstated. (1) CORRECT—ensuring that the older client's intake includes adequate protein is a challenge; important for an elderly client to ingest protein to keep organs functioning, and slows down the degeneration process (2)does need to limit fat and cholesterol in the diet, but no indication that client is ingesting too much fat (3)older adults usually require fewer calories; may require increased calories if recovering from surgery or illness (4)should drink adequate amounts of water to maintain hydration

The LPN/LVN cares for clients in a long-term care facility. The LPN/LVN learns that a client has a WBC count of 1,500/mm 3 . The LPN/LVN should take which of the following actions? 1. Move the client to a private room. 2. Monitor the client's vital signs every 8 hours. 3. Inspect the client's mucous membranes once per day. 4. Allow multiple staff to care for the client.

1. Move the client to a private room. Strategy: Determine the outcome of each answer. Is it desired? (1.) CORRECT— normal white count is 5,000 to 10,000/mm 3 ; client is immunocompromised; place in private room and instruct staff to practice scrupulous hand hygiene (2.) monitor vital signs every 4 hours; be aware of minor elevations in temperature (3.) check every 8 hours; observe for fissures and abscesses (4.) limit the number of staff caring for the client

he LPN/LVN cares for a client in the psychiatric unit who is experiencing alcohol withdrawal delirium. The LPN/LVN expects to administer which of the following medications? 1. Phenytoin sodium (Dilantin) and chlordiazepoxide (Librium). 2. Disulfiram (Antabuse) and chlorpromazine (Thorazine). 3. Disulfiram (Antabuse) and phenobarbital (Luminal). 4. Amitriptyline hydrochloride (Elavil) and alprazolam (Xanax).

1. Phenytoin sodium (Dilantin) and chlordiazepoxide (Librium). Strategy: Think about each answer. (1) CORRECT—anticonvulsants such as phenytoin sodium (Dilantin) and sedatives such as chlordiazepoxide (Librium) are used for delirium tremens; sedation used to control anxiety and agitation; anticonvulsants are used to prevent withdrawal seizures (2) disulfiram (Antabuse) is utilized to help client associate unpleasant experiences with the ingestion of alcohol; chlorpromazine (Thorazine) is an antipsychotic; side effect is postural hypotension (3) phenobarbital (Luminal) is an anticonvulsant; side effects include drowsiness, rash, and GI upset (4) amitriptyline hydrochloride (Elavil) is a tricyclic antidepressant; alprazolam (Xanax) is an antianxiety

The LPN/LVN cares for a homebound client diagnosed with thrombophlebitis. The health care provider orders the client to be on bedrest. It is most appropriate for the nurse to perform which activity? 1. Raise or lower head of bed every 2 hours. 2. Place client in the prone or supine position. 3. Encourage client to take a stool softener daily at bedtime. 4. Omit client's oral calcium supplements.

1. Raise or lower head of bed every 2 hours. Strategy: Determine the outcome of each answer. Is it desired? (1) CORRECT—maintains baroceptors to prevent decreased cerebral perfusion; if procedure is omitted, client is likely to faint when placed in a standing position (2) best position is on side to prevent distribution of weight over large bony prominences (3) more natural interventions recommended, such as adequate fluid and food fibers (4) bone demineralization likely to occur without normal weight-bearing; needs to continue taking calcium supplements along with adequate fluid intake

The LPN/LVN understands the primary purpose of performing a myringotomy for a client diagnosed with acute otitis media includes which reason? 1. Relieve pressure on the eardrum. 2. Remove embedded foreign body. 3. Avert the need for analgesia. 4. Removal of cerumen from auditory canal.

1. Relieve pressure on the eardrum. Strategy: Think about each answer. (1.) CORRECT—myringotomy is an incision made into the posterior inferior aspect of the tympanic membrane to relieve pressure and drain the middle ear (2.) associated with removal of drainage from inner ear; not associated with foreign body (3.) while acute otitis media can be painful, the primary reason is to remove fluid (4.) usually not needed; aiming the stream of water behind the obstruction aids in effective removal

The LPN/LVN cares for a client diagnosed with pneumococcal meningitis. The LPN/LVN determines that care is appropriate if which of the following precautions are used? 1. Standard precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.

1. Standard precautions. Strategy: Think about each answer. (1.) CORRECT— barrier precautions used with all clients to reduce the transmission of pathogens (2.) used for clients who have illness that is transmitted by airborne droplet nuclei (3.) used for clients who have illness that is transmitted by large particle droplets (4.) used for clients diagnosed with illnesses that are transmitted by direct client contact or by contact with items in the client's environment

A 29-year-old client who was told by the health care provider that she cannot have children subsequently forms a close attachment to a niece and nephew. The LPN/LVN understands this is an example of which defense mechanism? 1. Sublimation. 2. Projection. 3. Undoing. 4. Rationalization.

1. Sublimation. Strategy: Think about each answer. (1) CORRECT—is sublimating her desire to be a mother through a close attachment to her niece and nephew; by using sublimation, she can satisfy some of her unmet maternal instincts; will need to work through the issues of loss and the mourning process that usually accompany infertility (2) is not projecting her feelings of loss on others (3) client would pretend they were her children or communicate to others that she actually gave birth or planned to (4) an individual makes excuses for his/her behavior or attempts to justify unacceptable behaviors; developing close attachment to niece and nephew is not considered unacceptable unless interferes with safety and development of the children

An older client with benign prostatic hypertrophy had a transurethral prostatectomy yesterday. It is MOST important for the LPN/LVN to instruct the nursing assistants to perform which of the following activities? 1. Subtract irrigation fluid from total volume. 2. Turn, cough, and deep breathe client every 2 hours. 3. Assist the client with personal care. 4. Measure vital signs every 4 hours and report changes.

1. Subtract irrigation fluid from total volume. Strategy: "MOST important" indicates discrimination may be required to answer the question. (1.) CORRECT— because catheter can become obstructed or flow too rapidly and cause damage to the bladder; need to know is flowing at appropriate rate; also need to determine urinary output (2.) to maintain respiratory function, is part of post-operative care for any client (3.) although does not have a skin wound, will have pain and exhibit weakness and drowsiness associated with administration of general anesthesia and narcotics; is not directly related to this procedure (4.) is at risk for circulatory changes; should be monitored; less likely to occur than occlusion of the urinary catheter

A patient is ordered to receive an intravenous infusion of 3,000 cc of 0.9% NaCl over 24 hours. The nurse observes the rate is 150 mL/h. If the solution runs continuously at this rate, how many hours will it take to complete the infusion? Type the correct answer into the blank.

150cc/1h = 3000 cc/x h x=20 h

The LPN/LVN cares for a client diagnosed with clinical depression. The LPN/LVN teaches the client about the prescribed medications. It is MOST important for the LPN/LVN to include which of the following statements about the client's antidepressant medication? 1. "Antidepressants reverse the sequence of the sleep cycle." 2. "Antidepressants affect the function of norepinephrine and serotonin." 3. "Antidepressants promote the actions of estrogen and testosterone." 4. "Antidepressants affect the brain's ability to metabolize glucose."

2) CORRECT—it is well documented that these neurotransmitters are directly related to mood disorders; drug causes balancing of the chemicals, resulting in mood elevation Strategy: Think about each answer. (1) one side effect of the drug is drowsiness; can induce the sleep cycle (2) CORRECT—it is well documented that these neurotransmitters are directly related to mood disorders; drug causes balancing of the chemicals, resulting in mood elevation (3) although fluctuation of estrogen levels can affect the mood, drugs are not known to have significant impact on gender hormone levels or functions (4) brain glucose levels are known to have an influence on clients with schizophrenia; drugs are not known to have a clinical influence on the brain's use of glucose

The mother of a 6-month-old infant who received the DPT vaccine 3 days ago calls the LPN/LVN to report that the infant has been crying "nonstop" since receiving the injection. Which of the following responses by the LPN/LVN is BEST? 1. "Check your infant's mouth to see if teeth are erupting." 2. "Bring your child to the clinic as soon as possible." 3. "Apply an ice pack to the injection site." 4. "Has the infant had problems with 'colic' in the past?"

2. "Bring your child to the clinic as soon as possible." Strategy: "BEST" indicates that discrimination may be required to answer the question. (1) behavior not commonly associated with teething (2) CORRECT—reason for persistent, inconsolable crying is not known; is considered a moderate reaction which could also include convulsions, high fever, loss of consciousness; further investigation is needed (3) redness can occur at the injection site; pain at the site does not cause continuous crying (4) presumes the problems involve the gastrointestinal tract

The LPN/LVN performs a home care visit on a mother who delivered a baby 3 days ago. The client expresses alarm when she hears that her baby has lost 8 oz. Which of the following responses by the LPN/LVN is MOST appropriate? 1. "Perhaps you don't have enough milk for the baby and need to supplement his diet with formula." 2. "That is a normal weight loss. Babies sometimes lose as much as 10% of the birth weight." 3. "Babies usually lose some weight, but that's more than usual. He may need an intravenous infusion." 4. "Most babies immediately lose their intrauterine water deposits and 20% of their birth weight."

2. "That is a normal weight loss. Babies sometimes lose as much as 10% of the birth weight." Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. (1)does not identify that weight loss is normal for the newborn (2) CORRECT neonates can lose up to 10% of birth weight due to low levels of intake and excretion of fluids through lungs, bladder, and bowels; should regain weight by 10 to 14 days of age (3)weight loss is within normal limits (4)neonates excrete fluid but should only lose up to 10% of birth weight

The LPN/LVN assists the school nurse to teach a group of high school students about how to perform the Heimlich maneuver. The LPN/LVN determines that teaching is successful if a student makes which of the following comments? 1. "The Heimlich maneuver dislodges food or other foreign bodies from the airway." 2. "The Heimlich maneuver involves hitting the person on the back several times." 3. "The Heimlich maneuver should not be done if the person is unconscious." 4. "The Heimlich maneuver should be done only by a well-trained health care professional."

2. "The Heimlich maneuver involves hitting the person on the back several times." Strategy: "Teaching is successful" indicates correct information. (1) CORRECT—hands crossed at neck is universal sign of chocking; Heimlich maneuver is used to dislodge food or other foreign bodies in the airway (2) involves abdominal thrusts while standing behind the client (3) if unconscious, client should lie supine while the LPN/LVN straddles client's thighs; the LPN/LVN positions one hand over the other and places the heel of the bottom hand just above the client's navel; thrusts inward and upward toward the client's head (4) all adults should be taught how to perform the Heimlich as a part of first aid

A parent is concerned about the child's detached retina. The parent asks the LPN/LVN if a retinal detachment can be hereditary. The best response by the LPN/LVN includes which information? 1. "Have any of your other children had a detached retina?" 2. "There are no certain causes of retinal detachment." 3. "The cause of the retinal detachment was severe trauma." 4. "We should focus on preventing it from happening again."

2. "There are no certain causes of retinal detachment." Strategy: "BEST" indicates that discrimination is required to answer the question. (1.) caused by trauma, aging process, diabetes, and tumors (2.) CORRECT— this is the best response the LPN/LVN can give the child's parent because there are no certain causes of retinal detachment; a number of factors may contribute, including trauma, aging, diabetes, and tumors; has been found that clients who have a family history of retinal detachment or other ocular diseases are more prone to retinal detachment, but is not a hereditary disease (3.) no information given to support trauma (4.) since cause is unknown, no way to know how to prevent

While cleansing the wound of a school-aged child who fell from the roof of a storage building, the LPN/LVN overhears the parent and the client interacting. It is most important for the LPN/LVN to further assess if the parent makes which statement to the child? 1. "Maybe in the future, you will follow the rules." 2. "You know, of course, this means no dinner tonight." 3. "Why did you climb up there when I told you not to?" 4. "It appears that your injury isn't serious."

2. "You know, of course, this means no dinner tonight." Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1) parents are sometimes punitive when children are suffering the consequences of their behavior; they sometimes do this to reassure themselves that they were not at fault (2) CORRECT—indicative of improper disciplinary action; indicates also that this has been utilized before; supervising nurse needs to be involved (3) individuals often explore why others make certain choices; may need teaching about growth and development for this age group (4) reflects caring and compassion

The LPN/LVN prepares a client for a total laryngectomy. It is MOST important for the LPN/LVN to make which of the following statements? 1. "You will have no difficulty speaking after the surgery." 2. "You will not have an audible laugh after the surgery." 3. "The surgery will not affect your sense of taste or smell." 4. "After surgery, you will not be able to cough or sneeze."

2. "You will not have an audible laugh after the surgery." Strategy: "MOST important" indicates that discrimination is required to answer the question. (1)entire larynx, hyoid bone, strap muscles, and one or two tracheal rings are removed; client has no natural voice (2) CORRECT—essential that the LPN/LVN prepares the client for loss of verbal communication after a total laryngectomy; part of the preoperative care plan should include a mutual plan for alternative methods of communicating postoperatively; initially, client will use speech board, then use artificial larynx, then learn esophageal speech (3)will have diminished sense of taste and smell for a time after surgery; client will receive enteral feeding for 10 to 14 days postop; assess ability to swallow before removing feeding tube; begin with thick liquids, then introduce solid foods as tolerated (4)able to cough and deep-breathe effectively after surgery because there is no incision in the abdominal or thoracic cavity

he LPN/LVN monitors a client recovering from hepatitis B. The LPN/LVN understands the client has developed which type of immunity? 1. Antigen. 2. Active acquired. 3. Antibody. 4. Passive acquired.

2. Active acquired. Strategy: Think about each answer. (1) antigen is a protein that stimulates the production of antibodies; if a sufficient quantity of antigens invades the body, the immune response is stimulated (2) CORRECT—this client has actively acquired immunity, which means since he had the disease, he produced antibodies to fight the disease; another example of actively acquired immunity is immunization (3) immunoglobulin formed by the body in response to an invading antigen; antibodies neutralize or destroy antigens (4) natural passive immunity occurs when mother passes antibodies to the fetus; artificial passive immunity occurs when antibodies are injected into a client; provides temporary protection lasting for days to a few weeks

An African American female is diagnosed with breast cancer. It is most important for the LPN/LVN to take which action? 1. Use the same intervention for various emotional states. 2. Assess client's perception of the health care alteration. 3. Inform client that death rates are higher among African Americans. 4. Help client use effective coping skills that were utilized in the past.

2. Assess client's perception of the health care alteration. Strategy: "Most important" indicates that discrimination may be required to answer the question. 1) interventions should vary with the emotional states 2) CORRECT — interventions are more effective if they are based on assessment of the client's needs 3) although information is accurate, is likely increase anxiety level 4) assess before implementing; coping tends to be more effective if client utilizes skills that have been successful in the past

The LPN/LVN cares for a client diagnosed with bipolar disorder during a period of elation. The LPN/LVN follows the nursing care plan and chooses which of the following approaches when caring for the client? 1. Point out the effect the client's behavior has on others. 2. Attempt to distract and redirect the client. 3. Encourage the client to express himself. 4. Provide opportunities for the client to socialize.

2. Attempt to distract and redirect the client Strategy: Think about the outcome of each answer. Is it desired? (1) during manic periods, client has flight of ideas, is disoriented, talks excessively, jokes, dances, sings, is hyperactive; would be unable to deal with the impact of the behaviors on others (2) CORRECT—attempting to distract and redirect the client is the proper course; clients with mania have a tremendous amount of energy, for which they must have an outlet; attempts to confront or limit excessive activities usually lead to an increase in anger and frustration; by redirecting or distracting the client, the LPN/LVN recognizes the client's need for outlets and demonstrates acceptance and understanding of the manic individual's needs (3) during manic phase, client excessively expresses him/herself; important that the staff provide external controls; do not encourage client but help client channel expressions safely (4) during manic phase, important to decrease stimuli; assign to a single room away from activity, limit interactions with people; anticipate situation that will provoke or overstimulate the client

A 54-year-old client recently diagnosed with chronic kidney disease is learning to live with the disease. To aid in assuring the highest quality of life, the home care LPN/LVN instructs the client to include which daily activity? 1. Eat high-protein, low-carbohydrate diet. 2. Avoid large crowds and extreme temperatures. 3. Include bananas and oranges in the daily diet. 4. Weigh once weekly.

2. Avoid large crowds and extreme temperatures. Strategy: Think about the outcome of each answer. Is it desired? (1)protein should be limited to 1 g/kg; adequate carbohydrates need to be ingested to prevent excessive metabolism of proteins (2) CORRECT—goal is to reduce metabolic rate, resulting in fewer end products for the kidneys to convert; fever related to infections will increase the metabolic rate; infectious processes will increase the metabolic rate in response to the inflammatory process (3)both are high in potassium; poorly functioning kidneys cannot excrete potassium (4)should weigh daily

Which of the following approaches describes the correct technique for the LPN/LVN to obtain a urine specimen from a client who has an indwelling Foley catheter? 1. Empty the contents of the drainage bag, wait 10 minutes, and take a specimen of urine from the drainage bag. 2. Clamp the drainage tube below the port and, using a sterile needle, aspirate a specimen of urine via the port. 3. Swab the tubing with Betadine where the catheter connects to the drainage bag, disconnect the tubing, and collect a specimen of urine directly from the catheter. 4. Take a random specimen of urine from the drainage bag.

2. Clamp the drainage tube below the port and, using a sterile needle, aspirate a specimen of urine via the port. Strategy: Determine the outcome of each answer. Is it desired? (1) bacteria grow rapidly in the drainage bag (2) CORRECT—sterile technique is used; fresh urine sample obtained will ensure an accurate analysis (3) keep the drainage system closed to prevent introduction of microorganisms (4) do not collect urine from the drainage

During the acute phase of gout, which intervention by the LPN/LVN is most helpful to decrease pain during ambulation? 1. Perform passive range-of-motion exercises. 2. Encourage partial weight bearing. 3. Immobilize the extremity. 4. Restrict ambulation to inside the room.

2. Encourage partial weight bearing. Strategy: "MOST helpful" indicates that discrimination may be required to answer the question. (1.) need to determine methods to reduce discomfort during ambulation; passive exercises will maintain circulation and range of motion but will not help client "figure out" what works best during ambulation (2.) CORRECT—encouraging partial weight bearing, perhaps with a walker; a walker would relieve weight, pressure, and stress on the affected leg (3.) would not help client determine how to reduce pain during ambulation (4.) restricting site of ambulation would help client decide BEST method for relieving pain during ambulation; might consider ambulating when medication reaches the peak of its effectiveness

Which of the following nursing actions is MOST important for the LPN/LVN to take to provide effective pain relief for a client? 1. Teach the client about pain. 2. Establish a trusting relationship with the client. 3. Determine how various relaxation techniques affect the pain. 4. Administer pharmacological agents.

2. Establish a trusting relationship with the client. Strategy: "MOST important" indicates that discrimination is required to answer the question. (1)important to convey to the client in pain that the LPN/LVN believes the client's pain is real and that the LPN/LVN determines the effectiveness of the intervention for pain on the basis of the client's response (2) CORRECT—to effectively develop a plan of care for relieving a client's pain, trust is essential; pain is subjective, therefore decisions are based solely on client's report (3)is appropriate action, but LPN/LVN first establishes a trusting relationship (4)common pharmacological agents include aspirin, Tylenol, NSAIDs, and opiates; drug therapy is more effective when communication of needs is accurate

The LPN/LVN identifies which of the following diets as BEST meeting the needs of a person with multiple wounds? 1. High-protein, low-fat, high-iron diet. 2. High-vitamin C, high-protein, high-carbohydrate diet. 3. High-vitamin A, high-calcium, high-fat diet. 4. High-vitamin B, high-protein, low-carbohydrate diet.

2. High-vitamin C, high-protein, high-carbohydrate diet. Strategy: "BEST" indicates that discrimination is required to answer the question. (1)increased iron appropriate for client with iron deficiency anemia (2) CORRECT—increased vitamin C is essential to wound healing, and high protein is necessary for tissue growth; carbohydrate is needed for energy so the protein is properly utilized for repair of tissue (3)vitamin A contributes to night vision and growth of bones and teeth; vitamin A found in liver, fish liver oils, and fortified dairy products (4)high carbohydrates needed for energy

Following shift report, the LPN/LVN reviews the chart of a 62-year-old female admitted for dizziness and difficulty maintaining balance. The LPN/LVN reviews the client's record for potential causes for dizziness. The LPN/LVN identifies which of the following as MOST likely to cause dizziness and problems with imbalance? 1. History of migraine headaches. 2. Positive carotid arteriogram. 3. Fasting blood sugar 140 mg/L. 4. Hematocrit 44%, hemoglobin 14 g/dL.

2. Positive carotid arteriogram. Strategy: Think about each answer and how it relates to the symptoms. (1) some clients report light-headedness during an episode of an attack; anemia and poor circulation to the brain take priority over the circulatory problems associated with history of migraine headaches (2) CORRECT—obstructed carotid artery is likely to contribute to dizziness as well as problems with balance (3) normal level is 80-120 mg/dl; is not significantly elevated; is least likely to be the cause of the dizziness (4) normal hematocrit is 40-48% (woman); normal hemoglobin is 12-15 g/dL; anemia might cause dizziness; values within normal limits

Following an esophagogastroduodenoscopy (EGD) to sclerose exposed blood vessels, it is MOST important for the LPN/LVN to take which of the following actions? 1. Report client's inability or reduced ability to swallow. 2. Report vital sign changes and abdominal pain. 3. Instruct client to turn, cough, and deep breathe q 2 hours. 4. Assess vomitus for occult blood.

2. Report vital sign changes and abdominal pain. strategy: "MOST important" indicates discrimination may be required to answer the question. (1) an expected outcome due to application of local anesthesia (2) CORRECT—indicates hemorrhage (3) can prevent accumulation of respiratory secretion; unless respiratory compromise exists, would not be necessary; sedative effect is usually short-lived (4) because blood vessels are exposed, is likely to be positive; changes in vital signs and abdominal pain are indicative of potentially life-threatening situation

Due to manipulation of a central parenteral nutrition (CPN) catheter for a client during an MRI, 50 mL of the fat emulsion accidentally entered the CPN container. The next day, the LPN/LVN instructs the nursing assistive person to monitor for which response? 1. Allergic reaction. 2. Signs/symptoms of infection. 3. Increased serum glucose level. 4. Petit mal seizures.

2. Signs/symptoms of infection. Strategy: Think about the cause of each answer and how it relates to the accidental mixing of the solutions. (1) mixing of the solutions would not cause an allergic reaction (2) CORRECT—mixing solutions can increase the risk of infection; the CPN container should be discarded (3) because CPN contains 50% glucose, serum level is likely to be increased; is not related to mixing of solutions (4) seizure activity not related to CPN

The LPN/LVN observes one client screaming at his roommate, "You are always meddling in my side of the room and snooping around my property. I can't stand you anymore." The LPN/LVN should take which of the following actions? 1. Report the incident to the charge nurse as soon as possible. 2. Tell the client who is shouting, "You sound as if you are very angry with your roommate." 3. Tell both clients, "Let's a make a plan to avoid this kind of bickering again." 4. Say to the angry client, "Because you are out of control, you must leave the room."

2. Tell the client who is shouting, "You sound as if you are very angry with your roommate. Strategy: Determine the outcome of each answer. Is it desired? (1) situation is potentially volatile; need to defuse to some degree before leaving room (2) CORRECT—address the dominant member to restore control; the more passive client will probably remain quiet while the nurse tries to diffuse the anger of the aggressive client (3) contracting is appropriate for client, but first want to de-escalate the situation (4) punitive response; time-out is an appropriate intervention; this comment by the nurse will only escalate the situation

An elementary-school principal asks the school health nurse about the child-abuse prevention program operating at the school health care center. The LPN/LVN assists in preventing child abuse by performing which of the following? 1. The LPN/LVN reports potential abuse to the appropriate authorities. 2. The LPN/LVN participates in parental discussion groups after school. 3. The LPN/LVN informs the parents that if their attitudes don't change, action will be taken. 4. The LPN/LVN instructs the parents to permit children to stay with relatives until they are able to control their emotions.

2. The LPN/LVN participates in parental discussion groups after school. Strategy: Determine the outcome of each answer. Is it desired? (1) agency protocol requires a formal process; not part of the independent activities associated with the LPN/LVN role (2) CORRECT—providing opportunity for parents to discuss the challenges of parenting in an environment where there is time to problem-solve is likely to help them with day-to-day child-rearing activities (3) threats do not encourage individuals to cooperate with the person issuing the threats (4) further assessment is needed before implementing interventions

An elderly client on the medical/surgical unit receives a blood transfusion. The LPN/LVN believes the client is experiencing fluid overload caused by the transfusion. Which signs and symptoms confirm the LPN/LVN's conclusion? 1. The client's pulse rate decreases, the blood pressure increases, and the respirations decrease. 2. The client has an increased bounding pulse rate, an increased blood pressure, and increased respirations. 3. The client's pulse rate increases, the blood pressure increases, and the respirations decrease. 4. The client has a decreased pulse rate, a decreased blood pressure, and increased respirations.

2. The client has an increased bounding pulse rate, an increased blood pressure, and increased respirations. Strategy: Think about each answer. (1) if volume is significantly increased, pulse and respirations would increase together with the BP to compensate for the excess volume (2) CORRECT—if the blood transfusion is run rapidly and fluid overload occurs, signs of heart failure will be seen, including increased respirations, increased pulse rate, and increased blood pressure; bounding pulse is a landmark sign/symptom of hypervolemia (3) respirations always increase when blood pressure and pulse increase; there is an increased demand for oxygen (4) transfusion reactions cause decreased blood pressure that could lead to shock

The LPN/LVN reviews the history obtained from a client diagnosed with degenerative joint disease (DJD) of the right hip. The LPN/LVN identifies which of the following as risk factors for developing degenerative joint disease? Select all that apply: 1. The client had a transurethral resection of the prostate (TURP) 2 years ago. 2. The client worked as a carpet installer for 40 years. 3. The client is a 65-year-old male, height 6 feet, weight 280 lb. 4. The client was diagnosed with diabetes mellitus 10 years ago. 5. The client had a myocardial infarction at age 37.

2. The client worked as a carpet installer for 40 years. 3. The client is a 65-year-old male, height 6 feet, weight 280 lb. 4. The client was diagnosed with diabetes mellitus 10 years ago. Determine how each answer relates to degenerative joint disease. (1.) no relationship with prostatic hypertrophy and joint disease (2.) CORRECT— occupation that causes increased mechanical stress to joints, also would be 60+ years old (3.) CORRECT— seen after age 60 years, obesity causes stress to weight-bearing joints (4.) CORRECT— metabolic diseases (diabetes mellitus, Paget's disease) and blood disorders (hemophilia) can cause joint disease (5.) myocardial infarction is caused by coronary artery disease

The LPN/LVN observes a practical nursing student insert a nasogastric tube for enteral feedings. The LPN/LVN should intervene if which of the following is observed? Select all that apply: 1. The practical nursing student encourages the client to swallow while the tube is advanced. 2. The practical nursing student places the plastic nasogastric tube on ice. 3. The practical nursing student performs hand hygiene before beginning the procedure. 4. The practical nursing student puts on gloves before inserting the tube. 5. The practical nursing student advances the tube as the client is coughing. 6. The practical nursing student stands on the side of the bed opposite to the naris used for insertion.

2. The practical nursing student places the plastic nasogastric tube on ice. 5. The practical nursing student advances the tube as the client is coughing. 6. The practical nursing student stands on the side of the bed opposite to the naris used for insertion. " Should intervene" indicates incorrect actions. (1.) helps facilitate passing the tube (2.) CORRECT — might cause damage to mucous membranes because tube is stiff and inflexible (3.) appropriate action; decreases transmission of microorganisms (4.) appropriate action; decreases transmission of microorganisms (5.) CORRECT— if client coughs or chokes, pull tube back (6.) CORRECT — should stand on the same side of the bed

The LPN/LVN assists in planning care of a client diagnosed with antisocial personality disorder. The LPN/LVN understands that the purpose of group therapy for this client includes which of the following? 1. Provide extra time to explore the client's past. 2. Demonstrate acceptance of the client and his behavior. 3. Set limits on the client in a nonpunitive manner. 4. Encourage sublimation of the client's leadership potential.

3 Set limits on the client in a nonpunitive manner. Strategy: Think about each answer. (1) group therapy allows self-exploration with a therapist who can set appropriate limits on member's behaviors (2) want to convey acceptance of the client, but should deal with inappropriate behaviors (3) CORRECT clients with antisocial personality generally mistrust others and their motivations, which leads to manipulative, acting-out behavior; in order to establish trust and avoid power struggles, limits must be set in a nonpunitive manner (4) transforming unacceptable impulses and behaviors into socially acceptable behaviors; not the purpose of group therapy

The LPN/LVN cares for a client with a newly constructed ileostomy. The ostomy nurse visits the client to provide instructions about caring for the ileostomy. Which statement, if made by the client to the LPN/LVN, would cause the LPN/LVN to notify the ostomy nurse? 1. "The ostomy bag may need to be emptied four or five times daily." 2. "I know that if a leak occurs, I need to change the drainage bag immediately." 3. "I am looking forward to living without having this bag attached to me." 4. "I will notify the LPN/LVN immediately if my skin gets irritated."

3. "I am looking forward to living without having this bag attached to me. Strategy: "Would cause the LPN/LVN to notify the ostomy nurse" indicates incorrect information. (1) because flow occurs unpredictably throughout the day and the contents can be irritating to the tissue, will require frequent emptying (2) because can be irritating to tissue, need to change immediately (3) CORRECT—unlike a colostomy, drainage from an ileostomy is liquid and flows intermittently throughout the day for the rest of client's life; will need to wear bag all the time (4) because cannot move bag to another site, any skin irritation needs to be addressed immediately; skin breakdown is difficult to heal

The LPN/LVN assists the nurse in teaching a group of senior citizens about the importance of breast self-examination (BSE). It is MOST important for the LPN/LVN to include which of the following statements when instructing the seniors? 1. "Report to your health professional if your nipples become flat and elongated." 2. "Breast cancer is more likely to occur if you have a family history of breast cancer." 3. "Select a specific day of the month to perform the breast self-examination." 4. "As estrogen levels decrease, the likelihood of developing cancer also decreases."

3. "Select a specific day of the month to perform the breast self-examination." Strategy: "MOST important" indicates that discrimination is required to answer the question. (1.) normal occurrence due to atrophy of glandular tissue (2.) most clients diagnosed with breast cancer have no family history (3.) CORRECT— highest incidence of breast cancer is in women older than 65 years; because menses has ceased, instruct clients to select the same day each month to perform BSE (4.) mutation of breast tissue more likely to occur after menopause, when estrogen levels are at the lowest; may be associated with hormone replacement therapy

The LPN/LVN teaches an adult wellness class about how to prevent skin cancer. Which of the following statements by the LPN/LVN is BEST? 1. "Wear sunscreen if the temperature is above 80.0°F (26.7°C)." 2. "Wear a hat during the summer months." 3. "Stay indoors 11 AM-3 PM." 4. "Examine your body daily for any change to size and color of skin lesions."

3. "Stay indoors 11 AM-3 PM."Strategy: "BEST" indicates discrimination is required to answer the question. (1) wear sunscreen when going outdoors regardless of the temperature (2) wear hat and sunglasses when out in the sun (3) CORRECT—exposure to the sun is a major risk factor to developing skin cancer; wear sunscreen that is appropriate to a person's skin (4) examine body monthly; report any changes to health care provider

The LPN/LVN cares for clients in the long-term care facility. Which of the following clients should the LPN/LVN see FIRST? 1. A client diagnosed with type 2 diabetes has pale, cool skin and is complaining of a headache. 2. A client diagnosed with a CVA has frequent watery diarrhea. 3. A client diagnosed with asthma has labored breathing. 4. A client diagnosed with chronic renal failure has a B/P of 150/90 mm Hg.

3. A client diagnosed with asthma has labored breathing. Strategy: Determine the most unstable client. (1.) experiencing hypoglycemia; offer client a glass of milk (2.) second client to be seen; at risk for dehydration (3.) CORRECT — place client on oxygen; assess breath sounds (4.) no indication client is unstable

The LPN/LVN cares for clients in a long-term care facility. The LPN/LVN observes a staff member enter a client's room. The client is in a private room; the staff member wears a respiratory protective device, gown, and gloves; and the staff member closes the client's door after entering the room. The LPN/LVN determines that care is appropriate if the staff member is caring for which of the following clients? 1. A client diagnosed with influenza. 2. A client diagnosed with impetigo. 3. A client diagnosed with disseminated herpes zoster. 4. A client diagnosed with Legionnaires' disease.

3. A client diagnosed with disseminated herpes zoster. Strategy: "Care is appropriate" indicates a correct action. (1.) requires droplet precautions (2.) requires contact precautions; avoid placing in room with immunocompromised client (3.) CORRECT— requires both airborne and contact precautions (4.) requires standard precautions

The LPN/LVN informs a client diagnosed with angina about common side effects of nitroglycerin, including which of the following? 1. Palpitations, hypertension, and tachycardia. 2. Flushing, bradycardia, and muscle weakness. 3. Dizziness, headache, and hypotension. 4. Flushing, vertigo, and seizures.

3. Dizziness, headache, and hypotension. Strategy: If answer has multiple parts, all parts of the answer have to be correct. (1) increases collateral blood flow and causes dilation of coronary arteries; will cause hypotension, not hypertension (2) causes tachycardia and dizziness from vasodilation (3) CORRECT—because of the vasodilation, common side effects of nitroglycerin include dizziness, headache, and hypotension (4) does not cause seizures

The LPN/LVN cares for a client after rhinoplasty. The LPN/LVN observes bright red blood on the external dressing. Which action should the LPN/LVN take first? 1. Return the client to the operating room. 2. Contact the health care provider. 3. Examine the client's throat. 4. Perform nasopharyngeal suctioning.

3. Examine the client's throat. Strategy: "FIRST" indicates priority. (1) must assess first then validate findings with supervising RN; would not decide to return client to OR without consulting with assigned RN (2) observe pharynx with penlight; if bleeding noted, contact supervising nurse (3) CORRECT— gathering data is the first step of the nursing process; should observe for bloody drainage in the throat; hemorrhage is an emergency situation that requires the health care provider to repack internal dressing (4) nasal packing in place

The LPN/LVN notes orders for a client admitted with acute cholecystitis. The client has severe nausea and vomiting and reports severe abdominal pain radiating to the right shoulder. The LPN/LVN should question which order? 1. Insert nasogastric tube and attach to intermittent low suction. 2. Trimethobenzamide hydrochloride 200 mg per rectum (PR) tid. 3. Foley catheter to straight drain. 4. Nothing by mouth

3. Foley catheter to straight drain. Strategy: "Should question which order" indicates an incorrect order. (1) appropriate action for severe nausea and vomiting; achieves decompression of stomach (2) antiemetic; may cause drowsiness or dizziness (3) CORRECT— insertion of a foley is not necessary but is a potential source of infection and should only be used when absolutely necessary (4) NPO decreases stimulation of gallbladder and will help prevent nausea and vomiting

The LPN/LVN cares for a client 12 hours after a femoropopliteal bypass. It is most important for the LPN/LVN to place the client in which position? 1. Sitting up in straight-back chair. 2. High Fowler's with knee gatched. 3. Full supine. 4. Trendelenburg position.

3. Full supine. Strategy: Determine the outcome of each answer. Is it appropriate? (1) flexing at the hip can place at risk for occluding the artery, resulting in dislodgement of the graft; on bedrest for first 24 hours; assess for graft occlusion; client reports of ischemic pain similar to pain experienced before surgery (2) flexing the knee can impede circulation distal to the incision, causing increased pressure in the blood vessel and resulting in increased dislodgement of the graft (3) CORRECT—bending the hip and knee are contraindicated; instruct client to cough and deep breathe every 1 to 2 h and use incentive spirometer (4) promoting the flow of blood to vital organs such as brain and heart are not necessary after this procedure

A client experiences numbness and decreased sensation in both lower extremities during the course of treatment with vinblastine (Velban). The LPN/LVN should include which of the following nursing actions when caring for the client? 1. Soak both legs in hot water qid. 2. Increase walking to three times a week for 30 minutes. 3. Instruct client to ambulate carefully with broad-based gait. 4. Elevate the client's legs while sitting.

3. Instruct client to ambulate carefully with broad-based gait. Strategy: Determine the outcome of each answer. Is it desired? (1) vinblastine (Velban) is a vinca alkaloid; side effects include nausea, vomiting, stomatitis, and peripheral neuropathy; will cause extravasation; if it occurs, stop IV and apply moderate heat to the area of leakage (2) instruct client to report signs and symptoms of infection and bleeding (3) CORRECT—loss of reflexes and peripheral neuritis are potential side effects of the plant alkaloid vinblastine (Velban); may cause stumbling and falls (4) appropriate action for dependent edema

While preparing to administer medications, the LPN/LVN suspects an order dated 36 hours ago for levothyroxine (Synthroid) 0.01 mg has been transcribed incorrectly as 1 mg. Which of the following responses by the LPN/LVN is MOST appropriate? 1. Clarify error with transcribing person. 2. Report to the supervising nurse. 3. Review the original order. 4. Determine if client has received the incorrect dosage.

3. Review the original order. Strategy: "MOST appropriate" indicates discrimination may be required to answer the question. (1) need to verify concerns before communicating concerns; is not within role of LPN/LVN to discuss error with transcribing person (2) report after concerns have been verified (3) CORRECT—provides direct information with regard to the original source of information (4) after reviewing order, would be appropriate to determine if client has received dosage; at this point is only a suspicion; the correct dosage is 100 mcg rather than 1,000 mcg = 1 mg; best to follow through with concerns

A client diagnosed with inoperable cancer has difficulty walking after chemotherapy. When the LPN/LVN comes to assist the client to the bathroom, the client says, "Leave me alone. You treat me like a child." Which explanation is the best interpretation by the LPN/LVN of the client's behavior? 1. The client is frightened about falling. 2. The client is entering a regressive phase. 3. The client wants to maintain independence. 4. The client is angry about the nurse's interference.

3. The client wants to maintain independence. Strategy: "BEST" indicates that discrimination may be required to answer the question. (1) may be frightened of falling, but is probably more frightened about losing his independence (2) expressing concern about losing independence would not be considered regressive (3) CORRECT—clients are often frightened by dependence and have difficulty expressing their fear and anger to caretakers; they use projection and displacement to maintain a level of denial until they are ready to move toward acceptance (4) client is rejecting the person offering assistance and the environment, both of which represent the loss of his independence

The LPN/LVN identifies that a staff member is using standard precautions appropriately if which of the following is observed? 1. The staff member wears gloves when taking the blood pressure of a client diagnosed with AIDS. 2. The staff member irrigates an abdominal wound wearing a gown and gloves. 3. The staff member places contaminated linens in a leak-proof bag. 4. The staff member changes gloves when moving from one client to another.

3. The staff member places contaminated linens in a leak-proof bag. Strategy: Determine the outcome of each answer. Is it desired? (1)wear gloves when touching blood, body fluids, secretions, excretions, non-intact skin, and mucous membranes; not necessary to wear gloves when taking blood pressure unless client has drainage of body fluids or LPN/LVN has open wound on hands (2)should also wear mask or eye protection if splashes or sprays of blood or body fluid (3) CORRECT—prevents spread of contaminant to staff and throughout agency (4)always wash hands between contact with clients; wash hands immediately after removing gloves

The LPN/LVN in the outpatient clinic assists with an assessment on a client diagnosed with mastoiditis. The client reports experiencing chills, fever, nausea/vomiting, and a stiff neck. Which response is most appropriate? 1. "How high has the fever been?" 2. "How long have you had an elevated temperature?" 3. "What medication are you currently taking?" 4. "I need to have the charge nurse check you."

4. "I need to have the charge nurse check you. Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. (1.) degree of fever is not significant; will not aid in meeting client's immediate needs (2.) period has had fever is not significant; current status should take priority (3.) data is needed to aid in planning care; is not the FIRST priority (4.) CORRECT—mastoiditis is secondary to otitis media; chills, fever, nausea, vomiting, and a stiff neck are all signs and symptoms of a spread of the infection to the brain, which can occur as a result of untreated or inadequately treated mastoiditis; should take actions to meet client's immediate needs

After an abdominal aneurysm is discovered on a client who is planning a 4-week vacation trip around the world, the client begins to sob and expresses feelings of disappointment. Which of the following actions by the LPN/LVN is the MOST appropriate? 1. "Your trip can be rescheduled for this time next year." 2. "An abdominal aneurysm is a very serious problem." 3. "The surgeon is experienced and highly skilled." 4. "You appear disappointed about missing the trip."

4. "You appear disappointed about missing the trip." Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) negates client's feelings; is more concerned about the current situation; will take time to adjust (2) not likely to reduce negative impact of disruption in client's life; is still in shock at the loss of scheduled plans; not appropriate at this time (3) does not appear to be concerned about surgeon's skill at this time (4) CORRECT—acknowledges client's pain; shows compassion for client's dilemma; reflective statement allows client to verbalize feelings

The LPN/LVN is performing health screening on a group of people. The LPN/LVN identifies that which of the following individuals is at GREATEST risk for developing skin cancer? 1. A 15-year-old male with dark skin who works as a lifeguard at the local pool. 2. A 30-year-old female with light skin who works as a cashier at the local store. 3. A 47-year-old female with dark skin who swims daily at a health club. 4. A 62-year-old male with light skin who has worked as a roofer for 40 years.

4. A 62-year-old male with light skin who has worked as a roofer for 40 years. Strategy: "GREATEST risk" indicates priority. (1) risk factors for developing skin cancer include light-skinned races, people over the age of 60, and overexposure to sunlight; this person is exposed to the sun but has dark complexion and is young (2) light skin is a risk factor, but there's no indication that person is out in sun (3) is swimming indoors; not exposed to sun (4) CORRECT—over the age of 60, light-skinned, and works outdoors are all risk factors for cancer

The LPN/LVN contributes to the teaching of a client diagnosed with tuberculosis. The LPN/LVN explains that tuberculosis is caused by which reason? 1. A virus. 2. Poor sanitation. 3. Poor nutrition. 4. A bacterium.

4. A bacterium. Strategy: Think about each answer. (1) is not a virus; caused by the bacterium Mycobacterium tuberculosis ; transmitted via the aerosol route (coughing, laughing, sneezing, or singing); risk factors include close contact with an infected person, immunocompromised status, substance abuse, homelessness, poverty, minorities, children, people who are institutionalized, and those living in overcrowded, substandard housing (2) is a predisposing factor but does not cause the disease; improper disposal of contaminated materials can contribute to exposure to the microorganism but does not cause the disease (3) is a predisposing factor but does not cause the disease; malnutrition can result in reduced response to infection because of the immune system may be impaired; healthy clients can also contract the disease (4) CORRECT—caused by the bacterium Mycobacterium tuberculosis, transmitted via the aerosol route (coughing, laughing, sneezing, or singing)

The LPN/LVN begins the shift by assessing the clients. After making rounds, the LPN/LVN should FIRST contact the physician about which of the following clients? 1. A client with an obvious deformity of the right humerus. Extremity is warm to the touch with a palpable pulse. 2. A client is unconscious. Heart rate is 64 bpm and regular, and respirations are even and unlabored. 3. A client has multiple superficial scalp lacerations. Client is alert and responsive. 4. A client is restless. Client is pale, skin is cool and clammy, and abdomen is rigid with absent bowel sounds.

4. A client is restless. Client is pale, skin is cool and clammy, and abdomen is rigid with absent bowel sounds. Strategy: "FIRST" indicates priority. (1.) although the client likely has a fracture that will require further stabilization, there is no evidence of neurovascular compromise at present; does not take priority (2.) although the client is unconscious, cardiopulmonary assessment is stable; does not take priority (3.) although client may have circulatory compromise, the client is alert; ask nursing assistant to apply pressure to any areas where bleeding is not well controlled; requires further evaluation but does not take priority at this time (4.) CORRECT— appears to have severe circulatory compromise; most unstable client

The LPN/LVN recognizes that which of the following is an early symptom of gastric cancer? 1. Occult blood in the stool. 2. Vomiting. 3. Iron-deficiency anemia. 4. Abdominal discomfort relieved with antacids.

4. Abdominal discomfort relieved with antacids. Strategy: Think about each answer. (1) indicates advanced gastric cancer (2) indicates advanced gastric cancer (3) indicates advanced gastric cancer (4) CORRECT—other indications include indigestion, loss of appetite, bloated feeling, and weight loss

An elderly client is admitted for abdominal surgery. The admitting orders include activity as desired, standard bowel prep, and an intravenous infusion of 5% dextrose in water to infuse at 75 mL per hour starting at 6 PM. on the evening before surgery. The LPN/LVN understands that the primary purpose of administering intravenous fluids to a client before surgery include which of the following? 1. Provide a route for administering medications rapidly. 2. Avoid the need for inserting fluids on the morning of surgery. 3. Decrease the client's desire to take fluids by mouth. 4. Ensure that the client remains adequately hydrated.

4. Ensure that the client remains adequately hydrated. Strategy: "Primary purpose" indicates that discrimination is required to answer the question. (1)more appropriate after the procedure (2)IV the night before surgery ensures that client is hydrated (3)even with IV fluids, client may experience dry mouth and still desire oral fluids (4) CORRECT—bowel prep before surgery, especially in elderly people, can cause dehydration; starting the intravenous fluids in the evening ensures client is hydrated

A client is scheduled for a liver biopsy this afternoon. It is most important for the LPN/LVN to implement which nursing action prior to the procedure? 1. Ask client to turn to the right side. 2. Assess the client's right side for tenderness. 3. Assess breath sounds bilaterally. 4. Instruct the client to practice holding exhalations.

4. Instruct the client to practice holding exhalations. Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) more appropriate post-procedure to prevent or reduce the risk of bleeding (2) assessment of pre-puncture site for tenderness is not within the role of the LPN/LVN (3) because of the risk of puncturing the lungs during the procedure, is more appropriate after the procedure (4) CORRECT—causes liver to descend, decreasing the possibility of pneumothorax; position on right side for 1-2 hours after procedure; maintain bedrest for 24 hours; frequently assess vital signs

The wife of a client diagnosed with hepatitis B is given hepatitis B immune globulin (HBIG). The LPN/LVN understands that this offers which type of protection? 1. Complete. 2. Active acquired. 3. Antigen. 4. Passive acquired.

4. Passive acquired. Strategy: Think about each answer. (1) occurs through actively acquired immunity (2) body has come into contact with antigens and formed its own antibodies (3) protein that stimulates production of antibodies (4) CORRECT—immune serums such as HBIG contain gamma globulins in a concentration of about 16% and are obtained from hepatitis B-immune persons from the general population; provides rapid but short-lived protection against hepatitis B; close contacts of a client with hepatitis B receive this immunization by intramuscular injection; treatment is usually repeated after 28 to 30 days

A client is admitted to the hospital with a temperature of 101 F (38.3 C) and a WBC count of 3,000/mm 3. The LPN/LVN should institute which of the following precautions? 1. Contact precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Protective precautions.

4. Protective precautions. Strategy: Think about the outcome of each answer. Is it desired? (1)appropriate for wound infections, diseases caused by Clostridium difficile , infections caused by multidrug-resistant strains, respiratory syncytial virus; elevated temperature indicates possible infectious process; because client is immunosuppressed, need to protect client (2)appropriate for measles, M. tuberculosis, varicella, and disseminated zoster (3)appropriate for diphtheria, strep, pneumonia, influenza (4) CORRECT—client is immunosuppressed; place in private room, use proper handwashing before touching client and any of his belongings, limit number of staff caring for client; no fresh flowers or potted plants in the client's room

The day after the client's admission to the hospital, the LPN/LVN finds the client slumped on the floor with a razor blade in the left hand and blood pouring from the client's right wrist. It is MOST important for the LPN/LVN to take which of the following actions? 1. Ask the client why he is punishing himself this way. 2. Ask the client what precipitated the present crisis. 3. While a nurse assistant applies pressure to the wound, notify the physician. 4. Shout the agency emergency phrase and stay with the client.

4. Shout the agency emergency phrase and stay with the client. Strategy: "MOST important" indicates discrimination is required to answer the question. (1) the primary goal is to manage the current problem: risk of hypovolemia (2) current assessment should focus on immediate needs; because event/s leading to suicidal attempts are complex, diverse, and covert, may take days or weeks for client to fully respond to this question (3) the nurse should remain with client; if the LPN/LVN leaves the nursing assistant in the care of the client, the least trained person is in charge of a situation beyond his/her capabilities (4) CORRECT—best immediate response by the nurse; alerts the staff an emergency exists, which initiates assistance for the client and allows LPN/LVN to remain with client and apply pressure to the wound

An elderly client diagnosed with organic brain syndrome is hospitalized for dehydration. The LPN/LVN finds the client sitting in the client lounge and notes the client is incontinent of urine. Which of the following actions by the LPN/LVN is MOST appropriate? 1. Tell the client he will have to be catheterized. 2. Tell the client to go to the bathroom and put on clean clothes. 3. Scold the client for soiling himself. 4. Take the client to his room and assist the client to put on clean clothes.

4. Take the client to his room and assist the client to put on clean clothes. Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) dementia is organic condition characterized by impaired memory, abstract thinking, and judgment; LPN/LVN does not have the authority to make this statement; client has already urinated; will not need the procedure now and may not need it the next time; further assessment is needed (2) because client is confused, will require assistance (3) inappropriate; will not achieve professional goals commonly associated with management of the client with this health problem (4) CORRECT—take the client to his room for a change of clothes; conveys warmth and concern by responding kindly, openly, and honestly; do not leave the client alone

A person who has had sexual contact with a client with hepatitis B is given hepatitis B immune globulin (HBIG). The LPN/LVN explains to the sexual contact that the purpose of B immune globulin (HBIG) includes which of the following? 1. Prevents other sexually transmitted diseases. 2. Stimulates the immune system to develop antibodies to hepatitis B. 3. Prevents the development of hepatitis B. 4. Temporarily increases the contact's resistance to hepatitis.

4. Temporarily increases the contact's resistance to hepatitis. Strategy: Think about each answer. (1) not action of HBIG (2) describes active immunity, which is obtained through the hepatitis B vaccine (3) no guarantee that contact won't develop hepatitis B (4) CORRECT—an injection of pooled human gamma globulin is an example of passive immunity

The LPN/LVN performs a home care visit for a client who is receiving chemotherapy for treatment of cancer. The client's white blood cell count is 3,500/mm 3. Which of the following observations, if made by the LPN/LVN, requires an intervention? 1. The client cleans his toothbrush daily by washing it in the dishwasher. 2. The client eats peeled fruits and cooked vegetables. 3. The client takes and records his temperature each day. 4. The client eats rare meat.

4. The client eats rare meat. Strategy: "Requires an intervention" indicates incorrect information. (1) appropriate action; toothbrush can also be rinsed in liquid laundry bleach (2) eat a low-bacteria diet; don't eat salads or undercooked meat or season food with pepper; peeled fruits and cooked vegetables are appropriate (3) appropriate action; teach client to report signs or symptoms of infection to physician immediately (4) CORRECT—do not eat rare meat if immunocompromised

An adult client is seen in the clinic for acute otitis media. The LPN/LVN identifies which information in the client's history as most directly related to the development of otitis media? 1. The client smokes one pack of cigarettes per day. 2. The client had pneumonia as a child. 3. The client swims in a chlorinated pool. 4. The client had a cold 2 weeks ago.

4. The client had a cold 2 weeks ago. Strategy: "MOST directly related" indicates that discrimination is required to answer the question. (1.) cigarette smoking contributes to chronic airflow irritation; not related to otitis media (2.) since disease results after recent exposure to a microorganism, childhood pneumonia will not cause otitis media (3.) can cause external otitis, which is an infective, inflammatory, or allergic response to the external auditory canal; treatment includes application of heat and topical antibiotics (4.) CORRECT—acute otitis media is an infection of the middle ear; the cause is entrance of bacteria into the middle ear due to eustachian tube dysfunction related to infection or inflammation of surrounding tissue; if resistance is lowered, or the virulence of the organism is great enough, infection will result; in this case, client's resistance was lowered as a result of the cold 2 weeks ago

The LPN/LVN makes a home care visit to a client with a diagnosis of a right-sided stroke. The client's spouse states having frequent loose stools, and the health care provider diagnosed viral gastroenteritis. The LPN/LVN is most concerned with which observation? 1. The spouse washes the hands frequently. 2. The spouse drinks Gatorade. 3. The spouse takes antibacterial medications. 4. The client utilizes the commode immediately after the spouse.

4. The client utilizes the commode immediately after the spouse. Strategy: "MOST concerned" indicates that something is incorrect. (1) gastroenteritis is inflammation of the mucous membranes of small bowel; symptoms include nausea, vomiting, and diarrhea; frequent hand washing will prevent the transmission of the virus (2) fluid volume depletion can occur due to vomiting and diarrhea; instruct client to drink small amounts of Gatorade (clear liquid with electrolytes); Gatorade better than water, because water does not contain electrolytes (3) viral infections often result in superinfection by bacteria (4) CORRECT— after spouse uses commode, should be cleaned with cleanser such as chlorine bleach to prevent client developing gastroenteritis

The LPN/LVN assists in the care of clients in an inpatient psychiatric unit. The charge nurse is leading an adolescent social/support group to discuss the difficulties of growing up in the United States. The LPN/LVN understands the primary benefit of this type of group is based on which process? 1. The group's ability to evaluate own behavior. 2. The phase of the group's interaction. 3. The leader's skill in promoting progress. 4. The group members' sense of belonging.

4. The group members' sense of belonging. Strategy: Think about each answer. (1) most age-related groups focus on issues that are specific to their developmental age; may be supportive or educational (2) group members can benefit during all stages of group development; for example, members may benefit from helping establish group organization and boundary setting, participating in establishment of norms, and setting goals after the group terminates; this is not unique to adolescents (3) group leader in most groups initiates the group, provides continuity, and facilitates cohesiveness; is not unique to adolescents (4) CORRECT—adolescents are strongly influenced by their peers; the therapeutic benefit of this group can be enhanced through a sense of belonging in which they can establish norms for behavior and work through shared problems

A 3-year-old male child diagnosed with autism is admitted to the pediatric unit with a tracheotomy after having swallowed a small toy. The nursing assistant reports the child neither pays attention to the environment nor to the people around him. The LPN//LVN recognizes that which of the following is the BEST explanation for the behavior? 1. The child is frightened because he is in the hospital. 2. The child requires a neurological assessment. 3. The client is angry and deliberately ignoring those around him. 4. The inability to maintain eye contact is a characteristic of autism.

4. The inability to maintain eye contact is a characteristic of autism. Strategy: Think about each answer. (1) autism is impairment of social interaction; because of impaired communication, would be difficult to determine if client were frightened (2) no reason to perform a neurological assessment (3) the impairment reduces the client's ability to communicate; not enough evidence to determine if client is angry or determine deliberateness of the behaviors (4) CORRECT—client has low tolerance of stimulation; avoids environmental contact or stimulation by avoiding eye contact; is very typical of autism

he LPN/LVN discovers an unconscious person in the street and notes the person is not breathing. The LPN/LVN should take which action? 1. Lift the back of the person's neck. 2. Use the thumbs to move the person's lower jaw backward. 3. Turn the person's head to one side. 4. Tilt the person's head back and lift the chin.

4. Tilt the person's head back and lift the chin. Strategy: Determine the outcome of each answer. Is it desired? (1) airway will still be obstructed by the tongue (2) incorrect position; can result in potential airway obstruction (3) correct position to facilitate drainage; does not facilitate opening the person's airway (4) CORRECT— Tilt the person's head back and lift the chin.

The LPN/LVN knows that it is MOST important for which of the following patients to receive their scheduled medication on time? 1. A patient diagnosed with myasthenia gravis receiving pyridostigmine bromide (Mestinon). 2. A patient diagnosed with bipolar disorder receiving lithium carbonate (Lithobid). 3. A patient diagnosed with tuberculosis receiving isonicotinic acid hydrazide (INH). 4. A patient diagnosed with Parkinson's disease receiving levodopa (L-dopa).

. 1. A patient diagnosed with myasthenia gravis receiving pyridostigmine bromide (Mestinon). Strategy: "MOST important" indicates priority. (1.) CORRECT— Mestinon is a cholinesterase inhibitor that increases acetylcholine concentration at the neuromuscular junction; early administration can precipitate a cholinergic crisis; late administration can precipitate myasthenic crisis (2.) Lithobid is a mood stabilizer; targeted blood level is 1 to 1.5 mEq/L (3.) INH is given in a single daily dose; side effects include hepatitis, peripheral neuritis, rash, and fever (4.) L-dopa is thought to restore dopamine levels in extrapyramidal centers; sudden withdrawal can cause parkinsonian crisis; priority is to administer Mestinon

The LPN/LVN observes the interactions between a client diagnosed with a stroke and the family members. The LPN/LVN should intervene if which interaction is observed? 1. The adult child talks to the client while helping with the bath. 2. The spouse completes the client's sentence when the client has difficulty. 3. The adult child offers the client instructions one step at a time. 4. The grandchild faces the grandparent and speaks slowly.

. The spouse completes the client's sentence when the client has difficulty Strategy: "Should intervene" indicates an incorrect action. (1.) provides social contact; reduces sensory deprivation. (2.) CORRECT—will increase the frustration; allow client time to put his thoughts together and complete his sentence; interferes with rehabilitation process (3.) aphasia causes clients to have difficulty processing information; give the client a single instruction and allow the client time to complete the task before moving on to the next step (4.) appropriate action; allow the client time to process

The LPN/LVN cares for clients on an acute care inpatient psychiatric unit. The LPN/LVN knows that which of the following clients is MOST likely to successfully commit suicide? 1. A client diagnosed with substance abuse who planned how to commit suicide. 2. A client diagnosed with personality disorder who acted on an impulse to commit suicide. 3. A client diagnosed with depression who took an overdose of Tylenol. 4. A teen-aged girl who notified relatives about a plan to commit suicide. View Explanation

1. A client diagnosed with substance abuse who planned how to commit suicide. Strategy: Think about each answer. (1) CORRECT—suicide completers are generally men diagnosed with alcohol or substance abuse who usually plan the act (2) females are more likely to have personality disorders and more likely to attempt suicide on impulse; women attempt suicide more than men but have a low death by suicide rate (3) low lethal method; other low-level methods include slashing one's wrist and inhaling natural gas (4) females are more likely to conduct suicide gestures rather than suicide completion

The LPN/LVN assists in the management of the home care of an elderly client who has had pernicious anemia for 10 years. Because of a common complication associated with the disease, it is MOST important that the LPN/LVN instruct the client about which of the following procedures? 1. Gastroscopy. 2. Liver biopsy. 3. Complete blood count. 4. Bone marrow transplant.

1. Gastroscopy. Strategy: "MOST important" indicates discrimination is required to answer the question. (1) CORRECT—clients with pernicious anemia are more prone to gastric cancer and generally assessed via gastroscopy every 1 to 2 years (2) although RBC production is affected by this disease, the problem does not originate in the liver (3) excessive RBCs is a common sign/symptom of the disease, not a complication of the disease; CBC would not provide information about gastric cancer, which is a common life-threatening complication (4) although the disease is characterized by the bone marrow producing an excessive volume of RBCs, phlebotomy is the most common medical intervention

Because a client is diagnosed with end stage liver disease, the LPN/LVN knows which action should be included in the nursing care plan? 1. Administer aspirin for pain. 2. Administer fat-soluble vitamin supplements. 3. Monitor serum amylase levels. 4. Monitor serum calcium levels.

Administer fat-soluble vitamin supplements. Strategy: Think about the outcome of each answer. (1) aspirin increases clotting time; clients with impaired liver function are at risk for bleeding (2) CORRECT—impaired liver function results in reduced ability to synthesize fat-soluble vitamins; client will need additional volume to meet basic nutritional needs (3) more commonly associated with pancreatic disease (4) because of the risk of hyperphosphotemia, changes in calcium levels are more commonly associated with chronic kidney disease

The nurse teaches a group of women about how to perform breast self-examination. Place the following instructions in the correct order, beginning with the first action. All options must be used.

Strategy: Think about each answer. (1) look for any changes in appearance, asymmetry, nipple, or texture and for any discharge (2) while standing in front of mirror with arms at sides, inspect breast and nipples for asymmetry, changes, drainage (3) with hands firmly into hips and bow slightly, examine breast and nipples (4) with pads of fingers on left hand palpate the right breast using light pressure that feels the tissue just below the skin, medium pressure that feels the deeper tissue, firm that feels the tissue closest to the chest wall and ribs; this method feels all the breast tissue; then use the fingers of the eight hand to palpate the left breast; using a vertical pattern, the preferred method, palpate the entire breast from sternum outward including the Tail of Spence under the arm

While completing monthly drug update sheets at a nursing home, the LPN/LVN notes the sources of support available to each client. The LPN/LVN knows that a family member is MOST likely to visit or phone about the client if which of the following is true? 1. The client is a member of a local church. 2. The client has a daughter. 3. The client has two sons. 4. The client has a healthy sibling.

The client has a daughter. Strategy: "MOST likely" indicates that discrimination is required to answer the question. (1.) whether church members visit or call is related to size of church and role client played while active in the church (2.) CORRECT— daughters are more likely to attend to the care of an aging parent than are sons (3.) sons not as likely as daughters to visit or provide support (4.) not as likely to attend to client as the client's daughter

The LPN/LVN admits a new client to the long-term care facility. The LPN/LVN assesses the client's nutritional status. Which of the following observations by the LPN/LVN indicates that the client is adequately nourished? Select all that apply: 1. The client's conjunctiva is pale. 2. The client is 5 feet, 2 inches tall and weighs 125 pounds. 3. The client has spoon-shaped nails. 4. The client's hair is shiny and lustrous. 5. The client skin is rough, dry, and scaly. 6. The client's gums are pink in color

Think about each answer. (1.) indicates anemia; if client is well nourished, eyes should be clear, bright, and shiny with pink conjunctiva (2.) CORRECT — weight should be normal for body build and age (3.) indicates iron deficiency anemia, malnutrition (4.) CORRECT — if client is malnourished, hair may be stringy, dull, dry, and thin (5.) skin should be smooth and slightly moist (6.) CORRECT— if client is poorly nourished, gums will be spongy and will bleed easily

The nurse cares for children on the pediatric unit. A physician orders doxycycline (Vibramycin) 4.4 mg/kg IV once per day for a child weighing 88 lb. Record the correct amount of medication, in mg, that the child should receive for each dose. Type the correct answer into the blank. ___________

x mg/40 kg= 4.4 mg / 1 kg . x=179 mg