K PN-2018 5

The nurse performs a physical assessment of the precordium on an adult male. Identify where the nurse should place the stethoscope to auscultate the pulmonic area.

The pulmonic area is located in the second intercostal space just to the left of the sternum; auscultate for S2, caused by closure of the semilunar valves

Because a client is suspected of having a duodenal ulcer, the LPN/LVN expects to collect which of the following assessment data? 1. History of smoking. 2. Occult blood in stool.

(1) because smoking can increase secretion of HCL, may contribute to development of PUD; provides historical data but does not contribute to current status (2) CORRECT— duodenal ulcer is erosion of the mucosal wall of the duodenum; minute amounts of blood may exist in the stool

The LPN/LVN cares for a client with an IV ordered to infuse at 100 mL/hr into the left arm. Five hours after the IV is started, the LPN/LVN notes that 250 cc of IV fluids have infused. Which action by the LPN/LVN is most appropriate? 1. Notify the health care provider. 2. Assess the client's lung sounds and skin turgor.

(1) CORRECTcommon practice to adjust IV rate up to 25% without consulting with health care provider; to infuse the IV in the remaining 5 hours, the rate would have to be increased to 150 ml/hr, which is an increase of 33% (2) infusing the IV fluid too rapidly can result in hypervolemia, exhibited by lung congestion; volume received is less than prescribed

The LPN/LVN cares for clients in the outpatient clinic. A client comes to the clinic complaining of severe pain in the left leg that is not relieved by rest or medication. On physical examination, the LPN/LVN is MOST likely to observe which of the following? 1. Cold, mottled leg.

(1) CORRECT—pain in the lower extremities not relieved by rest indicates peripheral arterial disease; pain may be described as numbness or burning; pain sometimes relieved by placing leg in dependent position; skin is dry, scaly, dusky, pale, mottled, and cold

After the parent of an obese 17-year-old client is informed that the client is at 40 weeks' gestation and requires an emergency C-section, the parent exhibits behaviors indicative of a panic attack. To explain preoperative procedures to the parent, which approach by the LPN/LVN will be most successful? 1. Use short, simple sentences. 2. Explain the procedure in detail.

(1) CORRECT—panic-level anxiety is demonstrated by an inability to see and hear, inability to function; will have difficulty focusing; communication should be short, simple, necessary, and to the point (2) perception field is already overwhelmed; detailed information cannot be received, interpreted, applied, or retained

The nurse instructs a nursing assistive personnel (NAP) about how to empty a drainage evacuator. Arrange the following actions in the correct sequence from FIRST to LAST. All answers must be used. 1.Don gloves: use standard precautions 2.Compress the evacuator and replace the plug: removes drainage from wound; drainage serves as medium for infection 3.Elevate the bed to a workable height to ensure safety for staff 4.Pour drainage into measuring cup to examine color, consistency, and odor; notify physician if abnormal 5.Wash hands to prevent nosocomial infections

(1) Wash hands to prevent nosocomial infections (2) Don gloves: use standard precautions (3) Elevate the bed to a workable height to ensure safety for staff (4) Pour drainage into measuring cup to examine color, consistency, and odor; notify physician if abnormal (5) Compres the evacuator and replace the plug: removes drainage from wound; drainage serves as medium for infection

The LPN/LVN cares for a client diagnosed with cancer of the left breast. The LPN/LVN knows that breast cancer is MOST likely to metastasize to which of the following sites? 1. Gastrointestinal tract. 2. Bone

(1) common site for metastasis from melanoma, which is a malignancy of the skin; manifestations of melanoma include an irregularly shaped, pigmented mole or a mole that has red, white, and blue tones (2) CORRECT—a common site of metastasis from breast cancer is the bone; indications of bone metastasis include pain and local swelling

The LPN/LVN cares for a client during the recovery period after liposuction. As the LPN/LVN prepares to assist the client to the car, the client states, "I didn't know that I would need so many IVs. I kept getting more and more IV fluids." Which response by the LPN/LVN is best? 1. "It just seemed like a lot of fluids." 2. "I'm sure the health care provider knows what is best." 3. "I'll check your record to see how much IV fluid you received."

(1) nurse should follow up on client's observation (2) does not respond to what the client is saying (3) CORRECT— 2 to 4 mL/min is considered the normal range of IV solution for an adult; LPN/LVN should review client's record to determine how much IV fluid the client received

After being dialyzed, a client is admitted to the hospital with a diagnosis of acute kidney injury. The LPN/LVN is most likely to perform which nursing action? 1. Teach client the signs/symptoms of hyperkalemia. 2. Teach the client about the etiologies of the disease.

(1.) CORRECT— in acute kidney injury the kidneys cannot excrete potassium; slight fluctuations can be life-threatening (2.) altering conditions that caused the changes will not contribute to management of the current status; will be part of the teaching process, but will not be as life saving as teaching client about current, potentially life-threatening changes

As the LPN/LVN measures the blood pressure, the client tells the nurse that she has always had a heavy menstrual flow and needs extra iron. The LPN/LVN should recommend the client eat which of the following foods? 1. Chicken livers. 2. Pork.

(1.) CORRECT— liver is an excellent concentrated source of iron (2.) although pork liver is an excellent source of concentrated iron, pork in general is not a concentrated source of iron

The LPN/LVN cares for a client who just had a short leg cast applied. The LPN/LVN should perform which of the following actions? Select all that apply: 1. Cover the cast with a light sheet. 2. Handle the cast using the palms of the hands. 3. Elevated the affected limb to the level of the heart. 4. Compare the toes of the casted leg with those of the opposite leg. 5. Place a fan in the client's room. 6. Turn the client every 4 hours.

(1.) leave cast uncovered and exposed to the air (2.) CORRECT— prevents development of pressure area (3.) CORRECT — decreases edema (4.) CORRECT — assess for neurovascular functioning; also assess circulation, motion, and sensation in the casted extremity (5.) CORRECT — increases circulation of air in room to facilitate drying the cast (6.) turn the client every 2 hours to facilitate drying the cast, support major joints when turning

The LPN/LVN in the outpatient clinic is measuring the height of a 62-year-old client. The client expresses surprise at being 1 1/2 inches shorter. Which statement by the LPN/LVN is best? 1. "Having degenerative joint disease of the knees will cause your height to decrease." 3. "You are shorter as a result of having osteoporosis."

(1.) osteoarthritis only reduces spaces between joints; if spine bends because of changes, reduced height can occur; osteoporosis results in decreased height more readily than osteoarthritis (3.) CORRECT—osteoporosis leads to low bone mass, which results in fractures of spine, wrist, and hip; causes decrease in height

The LPN/LVN cares for clients diagnosed with Alzheimer's in the long-term care facility. The LPN/LVN identifies that which of the following is true about Alzheimer's? 2. Alzheimer's involves parasympathetic secretions. 4. Alzheimer's involves imbalances of dopamine and serotonin.

(2) CORRECT the forebrain is damaged in Alzheimer's disease, which results in low levels of acetylcholine (4) more common in clinical depression

The LPN/LVN cares for a client who has had a sustained temperature of 101.8 F (38.8 C) for 48 hours. After hypothermia therapy is initiated, the nurse notes the client begins to shiver. Which response by the LPN/LVN is best? 2. Turn off machine and notify health care provider. 3. Cover the client with extra blankets.

(2) CORRECT—shivering results in increased production of body heat (3) may be comforting to client but does not address cause of shivering

Because a client is scheduled for a cardiac catheterization within 14 days, it is MOST important for the home care LPN/LVN to take which of the following actions? 2. Inform the agency that there is a family history of latex allergies. 3. Instruct the client to eat a well-balanced diet and ingest adequate amounts of fluid

(2) latex allergies are believed to be related to amount of exposure more so than familial tendencies; if client is allergic, would document at the time (3) CORRECT—after a major invasive procedure, a well-nourished, well-hydrated client is least likely to be susceptible to sepsis; malnutrition and dehydration commonly associated with nosocomial infections

After administering 2 gtt of neo-synephrine 0.12% in the client's left eye, the LPN/LVN should take which of the following actions? 2. Press on the upper lid lightly with a cotton pledget. 4. Press the inner canthus firmly for 15 seconds.

(2) should not apply pressure over the cornea; medication is placed in the lower lid (4) CORRECT—prevents or reduces systemic absorption

The nurse in the long-term care facility cares for a client receiving chlordiazepoxide (Librium) 10 mg PO bid due to the unexpected death of her son. After administering the medication, it is MOST important for the LPN/LVN to instruct the nursing assistants to monitor the client for the following? .2 . .Anorexia and dry mouth. 4. Drowsiness and confusion.

(2) side effect of Ritalin is anorexia; dry mouth caused by the tricyclic antidepressants (3) more likely to experience constipation and depression (4) CORRECT—chlordiazepoxide (Librium) causes CNS depressant effects of drowsiness and sedation; caution should be used when driving or operating equipment; confusion may indicate an immediate need for reduction of dosage

The LPN/LVN cares for clients in the long-term care facility. As the LPN/LVN completes the admission form for a client, the LPN/LVN notes the client frequently changes the subject. It is MOST important for the LPN/LVN to take which of the following actions? 2. Focus on the client's physical symptoms. 3. Respect the client's behavior as necessary for relieving discomfort.

(2) the nurse obtains data about the client's psychiatric/psychosocial health, as well as physical data (3) CORRECT—because anxious clients have difficulty focusing, they attempt to decrease discomfort by relieving anxiety symptoms; nurse should assess client's level of anxiety, keep environmental stresses to a minimum, and maintain accepting and helpful attitude toward the client; if anxiety level remains high, notify nurse assigned to the case

An 8-month-old female presents with stunted growth and some perceptual problems. Chromosomal studies show that there are only 45 chromosomes. The LPN/LVN identifies the infant has which condition? 2. Down's syndrome. 3. Phenylketonuria. 4. Turner's syndrome.

(2) trisomy 21; clinical manifestations include brachycephaly, inner epicanthal folds, broad, short hands with transverse crease; mental retardation (3) inborn error of metabolism characterized by an inability to metabolize phenylketonuria (4) CORRECT—genetic abnormality resulting from a female having only one X chromosome; clinical manifestations include short stature, webbed neck, low posterior hairline, and shield-shaped chest

During peritoneal dialysis, a client suddenly begins to breathe more rapidly. Which action should the LPN/LVN take immediately? 2. Check the client's vital signs and elevate the head on pillows. 4. Elevate the head of the client's bed.

(2) vital signs are recorded every 15 min during the first few exchanges of peritoneal dialysis; if client is short of breath, elevate the head of the bed (4) CORRECT—will decrease the pressure of the dialysate on the diaphragm and increase the vital capacity of the lungs; draining the cavity of fluid will further decrease the pressure

The LPN/LVN assists the occupational nurse in planning a health program for a corporation whose employees range in age from 25 to 35 years. The primary focus of the health program should be which of the following? 2. Increase the employees' level of professional socialization. 3. Decrease the number of accidental injuries among the employees.

(2.) professional socialization helps employees gain knowledge and skills required for job performance; can reduce job-related stress (3.) CORRECT— unintentional injury is the number-one cause of death in young adults; is age-related because of willingness to take risks

As the nurse instructs a new mother on the care of her newborn's umbilical cord, the LPN/LVN demonstrates the procedure. The LPN/LVN determines teaching is effective if the client makes which of the following statements? 3. "I'll clean the cord and skin around it with alcohol." 4. "I'll wash off any drainage that collects around the cord."

(3) CORRECT clean cord and surrounding area with alcohol or erythromycin solution; report redness, drainage, or foul odor (4)cleanse with alcohol or erythromycin solution

The LPN/LVN knows that the major difference between preop medication given before general surgery and that given before cesarean section includes which of the following 3. The amount of narcotic given is lower. 4. All medications are routinely withheld.

(3) CORRECT lower level of narcotic given to prevent respiratory depression in the infant and drowsiness at birth; reversal of narcotics can be achieved by administering Narcan to the mother 15 min before delivery (4) preoperative medication is administered before cesarean section

During a home visit, the LPN/LVN reinforces client teaching performed at the outpatient clinic by asking the mother of a 6-month-old infant which foods she should omit from the child's diet. The LPN/LVN understands that which of the following foods is MOST likely to cause an allergy? 3. Fruits. 4. Eggs.

(3) applesauce, bananas, and pears are well tolerated; offer fruit juice only from a cup to prevent development of "nursing" caries (4) CORRECT—egg and meat proteins are highly allergenic compared with vegetable and grain proteins; introduce meat and eggs only when a child is close to 9 months of age, when the child is less likely to develop an allergy

An LPN/LVN cares for residents in an assisted living facility. The LPN/LVN discovers an unconscious client lying on the floor beside the bed with a small, open lesion on the right side of the head. After caring for the client, the LPN/LVN prepares to write an incident report. Which entry is most appropriate for the incident report? 3. "Apparently struck right side of head during fall." 4. "Nonresponsive client found lying on floor beside bed."

(3) no evidence that client fell nor that the head was struck in the process (4) CORRECT—incident should reflect exactly what the person completing the report saw, heard, touched, etc.

The LPN/LVN receives a phone call from a young adult diagnosed with type 1 diabetes treated with humulin insulin. Because the client experienced decreased sexual abilities, he began taking an herbal supplement that he learned about when watching television. Which of the following responses by the LPN/LVN is MOST appropriate? 3. "Stop taking the medication until you can consult with your physician." 4. "Did your blood sugar change after you started taking the herb?"

(3.) CORRECT— because client is not knowledgeable about either the disease or the global impact of drugs, it is important to communicate this information to the health care provider (4.) even if glucose level is unaffected, too many unknowns exist for client to continue ingesting the drug

The LPN/LVN cares for a conscious client diagnosed with severe ketoacidosis. The LPN/LVN is MOST likely to administer which of the following? 3. Regular insulin. 4. NPH insulin.

(3.) CORRECT— because regular insulin has a rapid onset and can be administered intravenously, it is the main therapeutic measure in the treatment of diabetic ketoacidosis (4.) because NPH has an onset of 6 to 8 hours, it does not match the urgency of the client's need; even if it could be administered intravenously, the onset would not meet the needs of a client with severe ketoacidosis

While documenting the health history, the LPN/LVN discovers that a 32-year-old woman is pregnant for the third time. The client has one living child and has had one abortion. The LPN/LVN accurately records the patient as which of the following? 2. Gravida II, para II. 3. Gravida III, para I.

(3.) CORRECT— client is experiencing her third pregnancy (gravida III), but in only one pregnancy did the fetus reach the age of viability (para I)

The LPN/LVN makes a monthly assessment of a 77-year-old client in the long-term care facility. It is MOST important for the LPN/LVN to report which of the following assessments to the health care provider? 3. The client complains of a hard, painless ulcer between the tongue and the floor of the mouth. 4. The client appears to have difficulty hearing when the TV is turned on.

(3.) CORRECT— indicative of possible oral cancer; common areas include lips, lateral aspect of tongue, and floor of mouth; predisposing factors include alcohol and tobacco use (4.) decreased hearing often related to aging process; can be augmented with prosthesis; places client at risk for sensory deprivation

The LPN/LVN assists the charge nurse in teaching clients how to prevent conception using the basal body temperature (BBT) method. The LPN/LVN determines teaching is successful if a client states which of the following? 3. "The basal body temperature remains unchanged." 4. "The basal body temperature rises slightly after ovulation."

(3.) temperature usually increases immediately after ovulation, if temperature remains elevated, pregnancy may have occurred (4.) CORRECT— just before ovulation, a woman's body temperature lowers about 1 degree; at the time of ovulation, the body temperature increases about 1 to 2 degrees; this slight rise is thought to be related to eruption of the follicle resulting in initiation of an inflammatory process

During a home visit, the LPN/LVN examines a client's new colostomy. During the visit, the client tells the LPN/LVN of plans to place the client's mother in a nursing home. The client states that during the last four family gatherings her mother acted confused and anxious. It is MOST important for the LPN/LVN to take which of the following actions? 3. Determine how the client is feeling about the decision. 4. Suggest the client observe her mother several times in her own home performing daily activities.

(3.) tremendous of guilt often follows this decision; family members need a great deal of support; children often regret they are unable to care for their parents; most important to validate the mother's status (4.) CORRECT— decisions about mother's mental status should involve viewing her in a quiet environment where the interaction is paced according to the mother's abilities; validate before implementing

The LPN/LVN assists the school nurse to care for students in the local high school. A student tells the LPN/LVN that the student's mother has been diagnosed with terminal cancer. Which of the following behaviors, if displayed by the student, should cause the LPN/LVN to report to the school nurse immediately? 2. The student has lost 10 pounds and appears very sleepy. 4. The student appears happy and gives valued items to close friends.

(4.) CORRECT — when planning suicide, clients often display exhilarated mood and offer valued possessions to close friends or family members; suicide rates are high among adolescents

The LPN/LVN assists with blood pressure screening at the local grocery store. Which blood pressure reading indicates possible stage 2 hypertension? 1. 160/110 mm Hg. 2. 150/94 mm Hg.

1) CORRECT— stage 2 hypertension is defined as systolic blood pressure at or above 160 mm Hg or diastolic at or above 100 mm Hg. (2) stage 1 hypertension; recheck in 2 months; teach regarding the importance of weight reduction, exercise, diet, and quitting smoking

The LPN/LVN learns that a client with a history of an aspirin allergy has been receiving ASA 81 mg PO daily for 2 days. Which action does the LPN/LVN take first? 1. Notify supervising nurse. 2. Administer diphenhydramine 50 mg PO prescribed for sleep. 3. Complete an agency incident report. 4. Observe for signs/symptoms of allergic reaction.

1) take care of the client first; supervising nurse needs to be aware of potential risks to client; LPN/LVN can delegate locating supervising nurse to another staff member 2) until risks to client are established, intervention should be delayed 3) not the first response; primary focus should be on meeting client's needs; incident report is part of long-term remedy of the occurrence of errors that place client at risk 4) CORRECTnbsp— put client safety first by observing, even though medication has been administered for two days

The LPN/LVN prepares to draw up medication from an ampule. The LPN/LVN should take which of the following actions? Select all that apply: 1. Perform hand hygiene. 2. Snap the neck of the ampule toward the hands. 3. Draw the medication slowly out of the ampule. 4. Expel aspirated air bubbles into the ampule. 5. Set ampule on flat surface and aspirate medication. 6. Cover needle with safety sheath.

1.) CORRECT— decreases transmission of microorganisms (2.) exposes the LPN/LVN to shattering glass; snap neck away from hands (3.) exposes medication to airborne contaminants; draw up medication quickly (4.) air pressure will force medication out of ampule; remove needle from ampule and expel air bubbles (5.) CORRECT — ampule can also be held upside down (6.) CORRECT— appropriate action

During instillation of epidural anesthesia for a woman before delivery, the monitoring devices indicate the client's blood pressure has dropped to 90/50. Which of the following responses by the LPN/LVN is BEST? 2. Administer oxygen (O 2) 2 L/min. 4. Assess the fetal heart tones (FHT).

2) CORRECT—<60 diastolic is insufficient profusion for both mother and fetus; immediate action is imperative; physician is occupied with anesthesia administration (4) priority is to oxygenate the mother

The LPN/LVN cares for clients on the medical unit. The LPN/LVN knows an EARLY indication that the client may be hypoxic includes which of the following? 2. Abnormal blood gases. 3. Elevated temperature.

2) CORRECT—blood gases measure tissue oxygenation, carbon dioxide removal, and acid-base balance; if client has inadequate exchange of oxygen and carbon dioxide, respiratory acidosis occurs, which would include a below-normal pH (3) hyperthermia is caused by infectious disease, heatstroke, or diseases of central nervous system

Ondansetron HCl (Zofran) 6 mg PO q 6 hr is ordered for a client. The LPN/LVN knows that which of the following times is the MOST appropriate to administer this medication? 2. 30 minutes before start of chemotherapy. 3. 2 hours after chemotherapy.

2) CORRECT—ondansetron HCl (Zofran) is a potent antiemetic with a 30- to 40-minute onset of action; side effects include constipation, diarrhea, fever, lightheadedness, and drowsiness (3) client may already be nauseated; given to prevent nausea

The LPN/LVN plans a Fourth of July cookout at the local park for nursing home residents. It is MOST important for the LPN/LVN to take which of the following actions? 2. Provide or apply sunblock to the residents' skin. 4. Arrange for a large tent to be erected over the serving area.

2.) fair-skinned clients are at risk for sunburn; all clients are at risk for overheating (4.) CORRECT— decreased sweat glands and decreased sensitivity of the hypothalamus can reduce the ability to respond appropriately to extreme temperatures; is at risk for hyperthermia

client is a multipara at 20 weeks' gestation. The client informs the LPN/LVN that her breasts are sensitive and sore. The charge nurse instructs the LPN/LVN to make which of the following suggestions? 2. Gently massage the breast with lotion and wear loose-fitting, comfortable clothing. 3. Apply cold compresses and wear a well-fitting, supportive bra.

2.) wash with warm water and keep dry; wear supportive bra; massage will increase circulation to the site and can further irritate and increase sensitivity (3.) CORRECT— breast soreness due to hormonal changes

By her fifth month of pregnancy, a 32-year-old prenatal multipara of average height and weight has gained 14 lb. The LPN/LVN recognizes that which of the following advice is needed? 2. The client has not gained enough weight and her diet should be reevaluated. 3. The client's weight gain is appropriate and she should continue on her present diet.

2.) weight gain is appropriate (3.) CORRECT— a 14-lb weight gain during first 5 months of pregnancy is appropriate

Several days postoperatively, the client reports pain, tenderness, and redness of the right calf. Which critical signs and symptoms does the LPN/LVN assess for next?3. Chest pain and shortness of breath. 4. Pain and tenderness in the right arm.

3) CORRECT — calf pain suggests the client may have a venous thromboembolism (VTE); place on bedrest with leg elevated until health care provider is notified and anticoagulant therapy is started; administer prescribed antibiotics 4) VTE is venous obstruction; will be localized to the area of the clot

The LPN/LVN instructs staff members about the care of a client diagnosed with cancer of the cervix. The client has internal radiation in place. The LPN/LVN should intervene if a staff member makes which of the following statements? 1. "I should allow the client to bathe herself." 2. "I should not stand at the foot of the bed." 3. "I should place all linens in a special, lead-lined hamper." 4. "I should wear a dosimeter while I am in the client's room."

3) CORRECT—sheets are not radioactive; save all dressing and bed linens in the room until after the implant is removed; dispose in the usual manner

The LPN/LVN cares for a client receiving the second day of total parenteral nutrition (TPN). The nursing assistant reports to the LPN/LVN that the client is having difficulty breathing. Which of the following actions should the LPN/LVN take FIRST? 3. Assess peripheral pulse proximal to the IV site. 4. Auscultate lungs and review intake/output records.

3) dyspnea would not be related to impaired circulation in the upper limb; impairment would be more likely to be centrally located (4) CORRECT—respiratory congestion is commonly associated with fluid overload; I/O records would help LPN/LVN determine if overhydration is the problem

The home care LPN/LVN visits a client undergoing external radiation for treatment of lung cancer. It is MOST important for the LPN/LVN to instruct the client about which of the following? 3. Apply sunscreen to the irradiated area if exposed to the sun. 4. Use a patting motion to dry the irradiated area.

3)do not expose area to sun or to heat (4) CORRECT—after washing, pat dry with soft towel or cloth; wear soft clothing that does not bind or rub

The LPN/LVN cares for clients on the medical/surgical floor. The LPN/LVN determines assignments are appropriate if which of the following clients is assigned to the LPN/LVN? 3. A client diagnosed with cellulitis receiving antibiotics. 4. A client with a mandibular fracture immobilized by wiring the jaw prepares for discharge.

3.) CORRECT — stable client with expected outcome (4.) requires discharge teaching regarding importance of oral hygiene and nutrition

The LPN/LVN observes a student practical nurse palpate uterine contractions. The LPN/LVN determines that the student is performing the technique correctly if which of the following is observed? 3. The student nurse places the fingertips on the fundus and presses gently. 4. The student nurse places the palms of the hands on either side of the abdomen and presses firmly.

3.) CORRECT— palpate with the fingertips; mild contractions: easy to indent with fingertips; moderate contractions: feels like touching the tip of the nose; fundus is difficult to indent: feels like touching the chin; fundus board-like and almost impossible to indent: feels like touching the forehead (4.) use fingertips on the fundus; contractions easier to detect over the fundus

The nurse cares for a client receiving cimetidine (Tagamet) by continuous IV infusion. The physician has ordered 900 mg infused over 24 hours. The medication is mixed in 500 cc of D 5 W and the IV unit delivers 60 drops per ml. The nurse should adjust the flow rate to deliver how many drops per minute? Type the correct answer into the blank.

Correct answer: 21 500x60/1440= 30000/1440 =21 drops/min

The nurse cares for a client diagnosed with spinal cord injury at the level of T1. The nurse notes profuse sweating, and the client complains of a pounding headache and nasal stuffiness. Arrange the following actions in the proper sequence from FIRST to LAST. All options must be used immediately. -Check the Foley catheter tubing for kinks or obstruction -Label the chart with a visible note about the risk for autonomic dysreflexia: -Place the client in a sitting position -Instruct the client about how to prevent autonomic dysreflexi - Place the client in a sitting position: lowers blood pressure immediately

Determine how best to decrease client's blood pressure. (1) Place the client in a sitting position: lowers blood pressure immediately (2) Check the Foley catheter tubing for kinks or obstruction: most common cause is distended bladder or constipation (3) Monitor the blood pressure every 10-15 minutes: if emptying the bladder or removing the fecal mass does not decrease blood pressure, hydralazine hydrochloride (Apresoline) is administered IV (4) Label the chart with a visible note about the risk for autonomic dysreflexia: ensures that staff is aware of risk (5) Instruct the client about how to prevent autonomic dysreflexia: instruct about signs/symptoms and causes (full bladder, impaction, pressure on skin, cool draft)

The LPN/LVN instills eyedrops for a client diagnosed with glaucoma. Which of the following are the appropriate techniques for the LPN/LVN to use when instilling the eyedrops? Select all that apply: 1. Ask client to look down, then retract the lower eyelid before instilling the drops. 2. Remove drainage along margin of the eye before instilling the drops. 3. Instruct the client to look up, retract the lower eyelid, and instill the drops. 4. Shake the bottle vigorously, place above the inner canthus, and instill. 5. Determine if the client has an allergy to latex. 6. Apply pressure to the outer canthus as the drops are instilled.

Determine the outcome of each answer. Is it desired? (1.) client should look up; instill drops in the lower lid (2.) CORRECT— drainage or crusting is a source of microorganisms (3.) CORRECT — eyedrops should be instilled in the lower conjunctival sac; instruct client to look up at the ceiling; this facilitates the correct placement of the drops and lessens the chance that the medication will hit the sensitive cornea of the sclera, causing injury (4.) shake bottle if instructions require the action; should avoid the inner canthus to prevent systemic absorption (5.) CORRECT— if client has latex allergy, use non-latex gloves (6.) both hands will be required to hold the bottle and for retraction of the lower lid

The nurse performs a physical assessment of the precordium on an adult male. Identify where the nurse should place the stethoscope to auscultate the tricuspid area.

Located in the fifth intercostal space at the lower left of the sternal border; auscultate for S1.

During a mountain climbing trip, the health care provider and the LPN/LVN assess a client with a deep partial thickness burn to the back. Which action by the LPN/LVN is the best initial action? 1. Break the blisters with scalpel using sterile technique. 2. Gently clean and then leave the area alone. 3. Apply a thin layer of petroleum gel to the area. 4. Wrap snugly with sterile gauze.

Strategy: "BEST" indicates priority. (1) blister provides a protective covering; leave intact (2) CORRECT—for a deep partial thickness burn, gently clean away debris and dirt; blisters form a protective cover, so leave intact, without applying a sterile gauze (3) application could result in rupture of the blister; need to be exposed to air to promote healing (4) may result in adherence of gauze to wound

A client asks the LPN/LVN, "What is the difference between rheumatoid arthritis and osteoarthritis?" Which response by the LPN/LVN is best? 1. "Rheumatoid arthritis is progressive and osteoarthritis is not." 2. "Rheumatoid arthritis is often treated surgically and osteoarthritis is not." 3. "Rheumatoid arthritis is a systemic disease and osteoarthritis is not."

Strategy: "Best" indicates that discrimination is required to answer the question. 1) rheumatoid arthritis is a chronic, progressive, systemic inflammatory process that involves many other systems; osteoarthritis tends to be localized and involves the musculoskeletal system 2) both types of arthritis can be treated surgically; because rheumatoid arthritis involves many other systems, osteoarthritis is treated surgically more than rheumatoid arthritis 3) CORRECT — osteoarthritis is a "wear-and-tear" disease; rheumatoid arthritis is a systemic inflammatory disease and tends to be bilateral, whereas osteoarthritis tends to be unilateral and involve weight-bearing joints; rheumatoid arthritis can affect any body system with connective tissue

The LPN/LVN finds a client with Ménière's disease leaning over the room's sink and clutching it with both hands. After determining the client is having an acute attack, which action should the LPN/LVN take first? 1. Help the client back to bed. 2. Instruct the client to lie down at the sink. 3. Massage the client's neck over the area of the carotid arteries. 4. Prepare to administer atropine sulfate subcutaneously.

Strategy: "FIRST" indicates priority. (1.) CORRECT—vertigo feels like room is spinning; may cause client to fall; lying down will prevent injury

The LPN/LVN helps the lead nurse teach prenatal classes in the antepartum clinic. Which of the following statements, if made by a client to the LPN/LVN, indicates that further teaching is necessary? 1. "I may feel hot flashes and chills." 2. "I may experience constipation." 3. "I may have leg cramps during the night." 4. "I may feel irregular, painless contractions."

Strategy: "Further teaching is necessary" indicates incorrect information. (1.) CORRECT— chills and fever indicate infection; report immediately to health care provider; not normal part of the antepartum period (2.) common discomfort of pregnancy; increase bulk foods, fiber, and fluid intake and encourage regular exercise (3.) common discomfort of pregnancy; increase calcium intake, flex feet, local heat (4.) normal discomfort of pregnancy; Braxton Hicks contractions; rest, change positions, practice breathing techniques

The LPN/LVN assists in admitting a client to the long-term care facility. The client is diagnosed with depression and is recovering from a drug overdose. It is MOST appropriate for the LPN/LVN to take which of the following actions? 1. Give the client a brief, clearly stated orientation to the unit. 2. Explain all of the unit activities that are available to the client. 3. Introduce the client to all of the nursing staff on duty. 4. Offer the client a list of choices and options available on the unit.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) CORRECT—because the depressed client's thinking is slowed, it is essential that the nurse take time to explain things clearly and to avoid long, complex explanations (2) avoid presenting choices, as client may feel too inadequate to make decisions (3) important to provide consistent daily care; one-to-one nursing care is ideal; make few staff changes because they may be seen as rejection (4) provide a structured, written schedule; avoid presenting choices

The LPN/LVN uses "return demonstration" to teach a client how to apply an ileostomy appliance. The client asks to omit the protective barrier. Which of the following responses by the LPN/LVN is MOST appropriate? 1. Ask client to discuss further his concerns. 2. Ensure that the bag fits snugly.

Strategy: "MOST appropriate" indicates discrimination may be required to answer the question. (1) CORRECT— otherwise, LPN/LVN will be making a decision with part of the data missing; increases error in decision making, placing client at risk (2) should fit snugly to prevent skin breakdown; does not address client's need

A police officer who works the night shift was recently diagnosed with type 1 diabetes mellitus. Because extensive exercise is required to meet job requirements, it is most important for the LPN/LVN to include which client instruction? 1. Do not exercise if the blood glucose is near normal. 2. Plan to eat a high-protein snack before exercising. 3. Exercise at the same time and the same length each day. 4. Weight lifting decreases the resting metabolic rate.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) should exercise when blood sugar is near normal; exercising increases blood sugar, which increases secretion of the growth hormone and the catecholamine levels, which results in hepatic release of glucose (2) should ingest carbohydrates to maintain glucose levels, or carbohydrates with protein; protein takes longer to convert to glucose than carbohydrates (3) CORRECT—consistency is the key to management of diabetes; because blood glucose is artificially controlled with the injection of insulin, client should cover peak action of insulin with food as well as eat additional food when physical activity is increased (4) increases the resting metabolic rate because it increases lean body mass

The LPN/LVN cares for a 73-year-old client immediately after a femoral-to-popliteal bypass graft. It is MOST important for the LPN/LVN to report which of the following observations to the supervising nurse? 1. Clammy skin. 4. Engorged neck veins.

Strategy: "MOST important" indicates priority. (1) CORRECT—hypovolemic shock is caused by an inadequate volume of blood caused by hemorrhage, severe dehydration, or burns; skin will be cold and clammy because the body redirects blood from the skin, kidneys, and GI tract to the brain and heart; urine output decreases; blood pressure will be decreased and pulse will be elevated (4) may indicate volume overload related to excess IV infusion, liver disease, or heart failure; indications of shock take priority

The LPN/LVN assists the campus nurse at the local university. A student who lives in a campus apartment is diagnosed with hepatitis A. It is MOST important for the LPN/LVN to take which of the following actions? 1. Arrange for delivery to the student of six small meals per day. 2. Arrange to have the student's homework delivered to a specific professor. 3. Arrange to have groceries delivered to the apartment on weekly basis.

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1) CORRECT—anorexia and malaise are common problems; provides for prepared meals; more likely to eat several small meals rather than three large meals; hepatitis A is transmitted through the fecal-oral route (2) health maintenance takes priority; will feel more like completing homework if nutritional needs are met (3) because malaise, fatigue, and anorexia are common problems, is not likely to prepare meals

The LPN/LVN cares for clients in a long-term care facility. The LPN/LVN plans to decrease influenza infections among the residents. Which of the following actions by the LPN/LVN is MOST important? 1. Encourage the staff to use good hand hygiene. 3. Administer the influenza vaccine to all staff members.

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1.) important for infection control; priority is to prevent the staff from bringing influenza into the institution (3.) CORRECT— administer the vaccine to all health care personnel, including pregnant staff; prevents transmission of flu from staff to clients at high risk for complications

The LPN/LVN understands that which of the following is the MOST significant risk factor for developing cancer? 1. Advancing age. 2. Smoking tobacco.

Strategy: "MOST significant" indicates that discrimination is required to answer the question. (1) CORRECT—single most significant risk factor; 50% of all cancers occur in people older than 65 years of age (2)tobacco is a carcinogen that contributes to lung, pharyngeal, esophageal, cervical, bladder, pancreatic, and kidney cancer

The physician orders a clear liquid diet for a client diagnosed with diverticulitis. The LPN/LVN instructs the family about the appropriate foods. The LPN/LVN should intervene if the client's family makes which of the following statements? 1. "Grandpa can have his daily glass of prune juice. 4. "Grandpa can eat a cherry popsicle with me."

Strategy: "Should intervene" indicates incorrect information. (1) CORRECT—clear liquid diet allows clear liquids (liquids that the LPN/LVN can see through or foods that are fluid at room temperature); prune juice allowed on a full liquid diet; diverticulitis is infection and inflammation of the diverticulum; signs include irregular bowel function with episodes of diarrhea, crampy pain in left lower quadrant, and low-grade fever Strategy: "Should intervene" indicates incorrect information. (4) popsicles (flavored and colored water frozen on a stick), tea, regular and decaf coffee allowed

The LPN/LVN performs diet teaching for a client with anemia. The LPN/LVN determines that teaching has been successful if the client selects which of the following menus? 1. Chicken salad, lettuce and tomatoes, and an apple. 2. Roast beef sandwich, cole slaw, and ice cream. 3. Liver and onions, spinach, and rice pudding with raisins. 4. Cheese omelet, toast, and fruit cocktail.

Strategy: "Teaching is successful" indicates correct information. (1) desired diet for iron deficiency anemia includes iron sources, as well as vitamin C to enhance the iron sources found in plants; chicken, especially dark meat, contains iron; tomatoes contain vitamin C; other foods listed do not contain significant amounts of iron or vitamin C (2) roast beef contains some iron; cabbage in cole slaw contains some vitamin C (3) CORRECT—contains high amount of iron; spinach contains vitamin C (4) doesn't contain iron or vitamin C

The LPN/LVN assists in the care of a client with a terminal illness. It is most important for the LPN/LVN to take which action? 1. Reassure the client of not being alone. 3. Be helpful to the client at all times

Strategy: Determine the outcome of each answer. Is it desired? (1) CORRECT—this is very important in the care of the dying client; fear of the unknown is frightening to dying clients; may become frightened of procedures and anything that reminds them that they will eventually die; need the continual reassurance that staff and family are available at all times and will be there for them (3) more important to convey that client is not alone; since nursing has boundaries and limitations, would be times when nurse could not be helpful

The nurse in the outpatient clinic performs a physical assessment of a client. Identify the location where the nurse palpates the client's femoral pulse.

Strategy: Remember anatomy. The femoral pulse is located below the inguinal ligament, midway between the symphysis pubis and the anterosuperior iliac spine.

After cholecystectomy, a client is returned to the room with a nasogastric tube connected to low intermittent suction. An IV of 1,000 mL D 5W 1/2 NS, a T-tube, and a Penrose drain are in place. The LPN/LVN understands which is the purpose of the Penrose drain? 1. Removes accumulated bile and blood from the wound. 2. Permits irrigation of the peritoneum with an antibiotic solution

Strategy: Think about each answer. (1) CORRECT— duct must be allowed to drain; bile would otherwise drain into the surrounding tissue, be very caustic, and cause problems for the client; type of drain tube is related to health care provider preference; T-tube use has become uncommon (2) the drain removes fluids

After a client attempted suicide, the LPN/LVN admitted the client to an inpatient medical unit. The client is LEAST likely to have the following psychiatric or mental disorder? 1. Obsessive-compulsive disorder. 2. Clinical depressions. 3. Schizophrenia. 4. Alcohol abuse.

Strategy: Think about each answer. (1) CORRECT—not likely to have an anxiety disorder (2) more likely to experience clinical depression; 15% of clients who end their lives have depression; bipolar clients are most at risk (3) 40% of clients with schizophrenia have suicidal thoughts; 20 to 40% make unsuccessful attempts (4) 25 to 50% of deaths by suicide are associated with alcohol abuse

The LPN/LVN understands the most important factor for maintaining adequate circulation includes which factor? 1. Blood volume. 2. White blood cell count. 3. Aerobic exercise. 4. Effective respiration.

Strategy: Think about each answer. (1) CORRECT—to maintain adequate circulation, an adequate transport medium to carry nutrients and gases throughout the body is needed (2) white blood cells (leukocytes) provide immunity and protect the body from infection (3) exercise during which oxygen is metabolized to produce energy (4) required to oxygenate the body

The physician orders a clear liquid diet for a client after an appendectomy. The LPN/LVN understands that the purpose of a clear liquid diet includes which of the following? 1. Provides adequate calories. 2. Relieves thirst and maintains fluid balance. 3. Stimulates the GI tract so the client will have bowel movements. 4. Provides complete nutrition

Strategy: Think about each answer. (1) clear liquid diet provides some electrolytes and carbohydrates but is inadequate in calories (2) CORRECT—offer clear fluids or foods that are fluid at body temperature; requires minimal digestion and leaves minimal residue; clear liquids are the initial feeding after surgery or parenteral nutrition (3) GI tract stimulated by the fiber; fiber increases peristalsis; goal is to limit stimulation until intestines heal (4) inadequate in all nutrients except for vitamin C

While working in an outpatient family planning clinic, the LPN/LVN overhears a client make a statement that suggests the client may have gonorrhea. Which statement is most likely to validate the LPN/LVN's suspicions? 1. "My boyfriend has a sore on his penis." 2. "I have a cheesy, white vaginal discharge." 3. "My boyfriend has a drip."

Strategy: Think about each answer. (1) indicative of syphilis; painless chancre that fades after 6 weeks (2) indicative of candidiasis (3) CORRECT men complain of urethritis and epididymitis with drainage from the end of the penis; women are frequently asymptomatic

The LPN/LVN identifies the average pulse range for an adult as which of the following? 1. 40-60/minute. 2. 60-80/minute. 3. 60-100/minute. 4. 70-110/minute.

Strategy: Think about each answer. (1)bradycardia; normal pulse rate for newborn is 120-140 bpm (2)normal pulse rate for preschooler is 80-140 bpm (3) CORRECT—normal pulse range for an adult is 60-100 bpm (4)normal pulse rate for school-aged child is 70-115 bpm

The LPN/LVN recognizes that which of the following signs is indicative of laryngeal cancer? 1. Increased drooling. 2. Blood-streaked sputum. 3. Difficulty swallowing.

Strategy: Think about each answer. (1)indicative of cancer of the brain (2)warning sign of lung cancer (3) CORRECT—hoarseness, difficulty swallowing, color changes in the mouth or tongue, and oral lesions that do not heal are warning signs of laryngeal cancer

The LPN/LVN implements the plan of care for a client requiring a fluid restriction. The goal for the client is to achieve the minimal acceptable output. The LPN/LVN determines that care is effective if which output is observed? 1. 200 mL/8 hours. 2. 280 mL/ 8 hours. 3. 760 mL/8 hours. 4. 1,000 mL/8 hours.

Strategy: Think about each answer. (1.) 200 mL per 8 hours = 25 mL/h; 30-40 mL/hour (average minimum) - 25 mL/hour indicates client is below minimal urinary output; (2.) CORRECT— 280 mL/8 hours = 35 mL/hour; minimal volume of urine needed to remove metabolic wastes from the body is 30-40 mL/hour; below this level could indicate kidney disease (3.) 760 mL/8 hours = 95 mL/hour; 95 mL/hour - 30-40 mL = 55-65 mL/h; higher than expected minimal range per hour (4.) 1,000 mL/8 hours = 125 mL/hour; 125 - 30-40 mL/hour = 85-95 mL/hour above expected minimal range per hour

meningococcal pneumonia 1. Standard precautions. 2. Airborne precautions. 3. Droplet precautions. 4. Contact precautions.

Strategy: Think about each answer. (1.) 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.) CORRECT— droplet precautions 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

The LPN/LVN observes a staff member enter the room of a client. The client is in a private room, and the staff member enters the room wearing a gown, gloves, and a respiratory protective device. 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 Pneumocystis carinii pneumonia. 2. A client diagnosed with pharyngeal diphtheria. 3. A client diagnosed with botulism. 4. A client diagnosed with tuberculosis.

Strategy: Think about each answer. (1.) requires standard precautions (2.) requires droplet precautions (3.) requires standard precautions (4.) CORRECT— requires airborne precautions

After a client has a simple vulvectomy, the nurse instructs the LPN/LVN to prepare the client for a sitz bath. The LPN/LVN instructs the client to keep the area clean and dry. The nurse understands that the reasons for these procedures include which of the following? 1. To d é bride the area and prevent wound infection. 2. To increase circulation to the area and promote wound healing. 3. To prevent swelling of the surrounding lymph nodes. 4. To cleanse the area and diminish the possibility of postoperative bleeding.

Strategy: Think about each answer. (1.) simple vulvectomy is removal of only tissue due to cancer of the vulva; debridement not necessary (2.) CORRECT— both of these measures can be done to increase circulation to a vascular region such as the vulva, helping to promote wound healing (3.) purpose is to increase circulation (4.) decrease incidence of postoperative infection; vasodilation could increase postoperative bleeding

The LPN/LVN understands which is the primary reason that older adults experience constipation? 1. They eat a small volume of food with decreased bulk. 2. They have less activity and decreased muscle tone. 3. They have neurological changes in the gastrointestinal tract. 4. They have decreased sensation in the gastrointestinal tract.

Strategy: Think about each answer. 1) capacity of stomach decreases; encourage to eat smaller, more frequent meals 2) CORRECT — after age 65, there is less peristalsis and decreased muscle tone in the GI tract; this, combined with the normally reduced activity of older adults, results in constipation; most seniors decrease their activity around the age of 65 to 70 3) neurological changes include decreased short-term memory and decreased reaction time, and sensory perceptual changes such as decreased hearing 4) decreased peristalsis occurs

To measure the pulse during adult cardiopulmonary resuscitation (CPR), the LPN/LVN should use which artery? 1. The femoral artery. 2. The radial artery. 3. The carotid artery. 4. The brachial artery.

Strategy: Think about the location of each artery. (1) located below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine; assess status of circulation to leg (2) found on thumb side of forearm at wrist; used to assess peripheral pulse (3) CORRECT—carotid artery is most accessible; if there is a weak pulse, it will most likely be felt in the carotid artery (4) found in groove between biceps and triceps muscles at antecubital fossa; used if performing CPR on infant

A toddler has a well-baby visit. The parents inform the LPN/LVN they will not permit administration of the MMR vaccine because of religious beliefs. Which response by the LPN/LVN is best? 1. Reinforce information about the consequences of omitting the immunization. 2. Reinforce teaching about how to care for the child if one of the diseases develops. 3. Complete the agency form for refusal or waiver of the immunization. 4. Ask a chaplain of the same religion to talk with the parents about the vaccine.

trategy: "Best" indicates that discrimination may be required to answer the question. 1) the parents have the right to refuse treatment without intimidation; the staff should honor religious beliefs 2) CORRECT — the primary focus is the safety of the child; the parents need to know signs/symptoms of the diseases along with management of the child's needs 3) because refusal of treatment could result in debilitating, maybe even fatal, disease, a form should be completed for the agency's protection; the form is not the primary focus of care 4) the LPN/LVN should leave consulting with a chaplain to the parents