NCLEX LPN Safety and Infection Control

The LPN/LVN observes a nursing assistant perform hand hygiene. The LPN/LVN should intervene if which of the following is observed? Select all that apply: 1. The nursing assistant inspects the skin of the hands for cuts. 2. The nursing assistant dries the hands starting with the wrist and moving down to the fingers. 3. The nursing assistant applies a small amount of lotion provided by the hospital. 4. The nursing assistant uses friction when washing hands. 5. The nursing assistant shakes the hands against the sink to remove excessive water. 6. The nursing assistant splashes water on own uniform.

" Should intervene" indicates something is wrong. (1.) appropriate action; observe for breaks in skin or dermatitis; report to supervising nurse before caring for clients (2.) CORRECT— dry hands starting with fingers, move to wrist, and then dry the forearms (3.) appropriate action for dry or chapped hands; use only the lotion provided by the institution because many lotions cause gloves to disintegrate (4.) appropriate action (5.) CORRECT— procedure should be repeated if hands touch the sink because the inside of the sink is considered contaminated (6.) CORRECT— encourages the growth of microorganisms

The LPN/LVN assists in the care of an 11-month-old toddler diagnosed with spastic cerebral palsy (CP). Because the parents are very concerned about their ability to meet their child's needs as she gets older, it is MOST important for the LPN/LVN to initiate which of the following teachings? 1. Encourage the parents to attend a local oxygen safety seminar. 2. Encourage the parents to meet with the physical therapist regarding helping the child with ambulation. 3. Encourage the parents to accept the child's limitations. 4. Encourage the parents to seek family counseling to prevent overindulgence.

(1) CORRECT—spastic CP is the most common CP; characteristic signs include increased stretch reflex, increased muscle tone, and weakness; upper extremities will have increased tone in shoulder adductor and internal rotator muscles, increased tone in elbow flexor and pronator muscles, and increased tone in wrist and finger flexor muscles; poor control of posture, balance, and coordinated motion; is at risk for aspiration and poor gas exchange due to decreased respiratory muscle function; child may be predisposed to frequent infections because of malnutrition, risk of respiratory aspiration, or weakened respiratory muscles (2) not likely to have the ability to ambulate; some have potential and can increase mobility levels; is not the most necessary client teaching (3) brain damage is permanent; not likely to regain function; with physical therapy and occupational therapy can help develop potential but not restore lost function (4) family counseling is appropriate; should not indicate why the family unit needs counseling

The fire alarm is ringing at a 50-bed nursing facility. Arrange the following actions by the nurse in the appropriate order from MOST important to LEAST. All options must be used. Pull the fire alarm after removing clients Move clients away from the fire: remember the acronym RACE (rescue/remove, alarm, confine/close, evacuate) Locate all of the residents: appropriate if evacuation required Close all of the fireproof doors: prevents fire from spreading

Determine the outcome of each answer. (1) Move clients away from the fire: remember the acronym RACE (rescue/remove, alarm, confine/close, evacuate) (2) Pull the fire alarm after removing clients (3) Close all of the fireproof doors: prevents fire from spreading (4) Locate all of the residents: appropriate if evacuation required

The LPN/LVN on the surgical unit administers an incorrect dose of medication to the client. The LPN/LVN should take which of the following actions? Select all that apply: 1. Record the dose of medication administered. 2. Photocopy the incident report for the nurse's personal files. 3. Perform an assessment of the client. 4. Contact the supervising nurse. 5. Chart any adverse reaction the client experienced. 6. Write an incident report 48 hours later.

Determine the outcome of each answer. Is it desired? (1.) CORRECT— record the dose of medication administered and dose of medication ordered (2.) do not make a copy because can be subpoenaed in court; nurse should keep a written account of incident for personal files (3.) CORRECT— assess and factually record client's response (4.) CORRECT— supervising nurse will notify the physician; after physician is notified, record any action taken by physician (5.) CORRECT— record factually; also record staff's response to adverse reaction

The nurse instructs a student nurse about the correct way to prepare a sterile field. Place the following instructions by the nurse to the student nurse in the correct order from the FIRST action to the LAST. All options must be used. Place sterile drape on the work surface: hold drape away from body; lay bottom half of drape on work surface and then the top half of the drape Assemble the necessary equipment: prevents breaks in technique Dispose of outer wrapper: prevents accidental contamination of sterile field Open wrapper of sterile item: appropriate after assembling necessary equipment and placing sterile drape on work surface

Strategy: Think about each answer. (1) Assemble the necessary equipment: prevents breaks in technique (2) Place sterile drape on the work surface: hold drape away from body; lay bottom half of drape on work surface and then the top half of the drape (3) Open wrapper of sterile item: appropriate after assembling necessary equipment and placing sterile drape on work surface (4) Dispose of outer wrapper: prevents accidental contamination of sterile field

The wife of a client in the advanced stages of Parkinson's disease tells the LPN/LVN that she is getting weary of the daily, seemingly insurmountable tasks required to maintain her husband's health. Which of the following actions by the LPN/LVN is BEST? 1. Assist the wife to plan time for her individual needs. 2. Help the wife understand caregiver fatigue is a common occurrence. 3. Suggest to the wife that she obtain a prescription for an antidepressant from the health care provider. 4. Help the wife identify the particular part of his care that makes her weary.

Strategy: "BEST" indicates discrimination may be required to answer the question. (1) CORRECT—nursing care plan should include the needs of the family unit; like other health care providers, the family caregiver's personal needs should be addressed; because many family caregivers often feel guilty about wanting personal time, will probably need assistance planning for personal needs; weariness could result in fatigue, resulting in high risk of error or in neglect or abuse (2) although can be reassuring, offers no remedy for the problem (3) further assessment is needed before coming to conclusion (4) all care needs to be performed; communication indicates feeling overwhelmed; not likely to be able to specify particular element; may feel guilty about finding any portion of the care distasteful

While admitting a client for a laparoscopic cholecystectomy, the LPN/LVN learns the client may be allergic to an antibiotic but is not sure which one. After learning ticarcillin (Ticar) 3 g IV q 6 h is ordered, which of the following actions by the LPN/LVN is BEST? 1. Consult with the supervising nurse. 2. Administer drug and monitor client. 3. Ask client to describe signs/symptoms. 4. Ask client why the previous antibiotic was ordered.

Strategy: "BEST" indicates discrimination may be required to answer the question. (1) CORRECT—ticarcillin (Ticar) is an extended-spectrum penicillin; if allergy is suspected, common drugs that are high allergens such as penicillin, sulfa, and cephalosporins should be avoided; consulting with supervising nurse will help develop a plan for managing the problem (2) because allergic reaction can be life-threatening, should take all necessary precautions to prevent placing client at risk (3) signs/symptoms of allergic reactions are similar across drugs; also signs/symptoms are variable for same drug; can be mild at one time and severe at another; side effects include diarrhea, rashes, hypokalemia, and anaphylaxis (4) not relevant to current situation; because many drugs are broad spectrum and can be ordered for various purposes, information may not be helpful; also, many drugs are ordered prophylactically as well as for specific purposes

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?"

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

Because of religious beliefs, the parents of a toddler inform the LPN/LVN at a well-baby clinic that they will not permit administration of the MMR vaccination. Which of the following responses by the LPN/LVN is BEST? 1. Inform the parents of the consequences of omitting the immunization. 2. Teach parents how to care for child should one of the diseases develop. 3. Complete agency form for refusal or waiver of immunization. 4. Ask a chaplain of the same religion to talk with parents about the vaccine.

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1) have right to refuse treatment without intimidation; should honor religious beliefs (2) CORRECT—primary focus is the safety of the child; 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, form should be completed for the agency's protection; is not the primary focus of care (4) should leave consulting with chaplain to the parents

Before religious services began, an LPN/LVN noticed a small child with an irregular, unstable gait running up and down the aisles with a small piece of candy in his mouth. Which of the following actions by the LPN/LVN is BEST? 1. Gently remove the candy from the child's mouth. 2. Locate the parents and inform them of the risks. 3. Monitor the child while another person searches for the parents. 4. Take the child to the area in the building designed for children.

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1) should not attempt to remove candy without permission of the legal guardian (2) should remain with the child; unstable gait places at risk for aspiration of the candy, resulting in occlusion of the airway (3) CORRECT—protects the child from injury or damage while operating within legal guidelines (4) should not take possession of the child

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? 1. Inform anesthetist about the problem. 2. Administer oxygen (O2) 2 L/min. 3. Assess the apical and peripheral pulses. 4. Assess the fetal heart tones (FHT).

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1) will be occupied completing the anesthesia (2) CORRECT—<60 diastolic is insufficient profusion for both mother and fetus; immediate action is imperative; physician is occupied with anesthesia administration (3) diastolic blood pressure <60 is sufficient evidence for immediate action (4) priority is to oxygenate the mother

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.

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 cares for a client 3 days after a complete cystectomy and ileal conduit. Which of the following observations would cause the LPN/LVN to contact the supervising nurse? 1. The output is 60 cc per hour. 2. The stoma appears red in color. 3. The stoma appears edematous. 4. There is a small amount of serosanguineous drainage.

Strategy: "Cause the LPN/LVN to contact the supervising nurse" indicates a complication. (1) appropriate output; monitor urine output every 1-2 hours in the immediate postop period; compare output with intake; decreased output indicates obstruction or dehydration (2) expected color; ileal conduit is formed when both ureters are attached to a segment of ileum, which is brought to the surface of the lower abdomen to form a stoma to drain urine; notify physician if stoma is grayish-blue or pale in color; assess that appliance fits around stoma to prevent skin breakdown (3) CORRECT—edema can cause obstruction of stoma; also observe for excessive bleeding or enlargement of the stoma (4) expected outcome

A half hour after a bone marrow biopsy, the client tells the LPN/LVN that "the RN told me to get up and walk in the hall." Which of the following responses should the LPN/LVN make FIRST? 1. "I'll have to talk with the supervising nurse." 2. "I'll help you back to your room." 3. "I need to look at the bone marrow aspiration site." 4. "Your gait appears to be stable."

Strategy: "FIRST" indicates priority. (1) because LPN/LVN is aware client is at risk, need to address immediate risks; priority is to ensure that homeostasis has been achieved (2) CORRECT—client at risk for bleeding and circulatory shock; should be on bedrest; after making sure client is safe, LPN/LVN can address client communication with the RN at a later time (3) can be done after client has returned to the assigned room (4) focus of stability rests more with the cardiovascular system than with musculoskeletal system

A client diagnosed with acute lymphocytic leukemia (ALL) reports having frequent severe headaches. The health care provider prescribed ibuprofen (Advil) 800 mg q 6 h po prn for headache. Which of the following actions should the LPN/LVN take FIRST? 1. Administer medication with food. 2. Review order with supervising nurse. 3. Instruct client to report gastric discomfort. 4. Report non-relief of the headache.

Strategy: "FIRST" indicates priority. (1) irritates gastric mucosa and should be taken with food; teaching should occur after order meets all criteria for implementation; mismatch of disease process and drug side effects needs further investigation (2) CORRECT—clients with ALL are at risk for bleeding; drug can delay clotting, resulting in increased risk for hemorrhage; health care provider needs to be notified (3) causes gastric irritation that can result in gastric bleeding; should report the signs/symptoms; but is part of implementation; order does not meet all of implementation criteria (4) is part of implementation; no need to teach about drug because it's contraindicated for this client

While preparing a 15-year-old female for the surgical removal of a lipoma, the LPN/LVN is told by the client that her 18-year-old boyfriend is physically abusive. Which of the following actions should the LPN/LVN take FIRST? 1. Discuss the matter with the client's parents without obtaining client's consent. 2. Consult with the supervising nurse. 3. Implement agency policy for prevention of family violence. 4. Notify hospital security immediately.

Strategy: "FIRST" indicates priority. (1) is a process outside common activities for work area; need to confer before making decision (2) CORRECT—need to verify LPN/LVN role regarding addressing this issue by consulting with individual closer to policy setting (3) stay within chain of command; policies are often vague and applicable to many situations; need to confer with supervisor to determine the best pathway suited for the situation (4) currently, client does not appear to be at risk

The LPN/LVN cares for clients in the outpatient clinic. A client who appears to be in severe pain states, "I think I have a piece of glass in my eye." Which of the following actions should the LPN/LVN take FIRST? 1. Attempt to remove the impaled glass using tweezers. 2. Douse the affected eye with artificial tears. 3. Assess visual losses in the affected eye. 4. Place client in safe and comfortable position.

Strategy: "FIRST" indicates priority. (1) is outside the competencies as well as the legal role of the LPN/LVN (2) primary principle is to prevent further damage to the eye; any activity that could cause movement of the foreign object should be avoided (3) is at risk for loss of vision or loss of the eye; role of LPN/LVN is to maintain circumstances as they are until the appropriate person can attend to the client (4) CORRECT—the LPN/LVN should make sure client is in a position that prevents movement of the object, then notify the nearest RN or health care provider

The LPN/LVN cares for a patient admitted with a diagnosis of myasthenia gravis. The physician writes the following orders: warfarin (Coumadin) 2.5 mg po daily, prothrombin time (PT) q A.M. at 0600, and electromyography (EMG). Which of the following actions should the LPN/LVN take FIRST? 1. Determine what time the EMG will be performed. 2. Review textbook for time of onset of warfarin (Coumadin). 3. Find out why physician ordered warfarin (Coumadin). 4. Determine if sedative or tranquilizer is prescribed for EMG.

Strategy: "FIRST" indicates priority. (1) need to know onset of Coumadin effectiveness before determining most appropriate time for EMG (2) CORRECT—procedure requires insertion of needle deep into voluntary muscle tissue for assessment of neuroelectrodynamic activity; if therapeutic effects of Coumadin have begun, would be at risk for extensive bleeding; bleeding not only places client at risk for hypovolemia and hematoma formation but blood would interfere with transmission of electrical waves; because Coumadin onset is 1-1.5 days, having test the same day therapy is initiated would be appropriate (3) knowledge of specific purpose is not relevant; need to be coordinated with scheduling of the EMG (4) because client needs to be cooperative, is contraindicated

A neighbor of the LPN/LVN calls because the neighbor's 3-year-old daughter has been vomiting and has had frequent diarrhea for the past 3 days. Which of the following actions should the LPN/LVN take FIRST? 1. Measure the vital signs. 2. Offer her electrolyte-balanced fluid. 3. Take the child to the emergency room. 4. Call the child's pediatrician.

Strategy: "FIRST" indicates priority. (1) regardless of the vital-sign range, can offer no treatment (2) commonly used as replacement fluid in pediatric clients; should be seen by health care provider (3) CORRECT—due to length of illness, child should be seen by health care provider (4) after this time period, is at risk for serious health alterations; needs care as soon as possible; make not be able to reach pediatrician; needs to be directly assessed physically

While providing care for a client with an abdominal wound, the LPN/LVN notes that there is purulent drainage from the wound. Which of the following actions should the LPN/LVN take FIRST? 1. Contact the supervising nurse. 2. Place the client on contact precautions. 3. Irrigate the wound. 4. Ask the client if he is experiencing pain or tenderness.

Strategy: "FIRST" indicates priority. (1)should take steps to place client on contact precautions to prevent spread of infection to other clients; another staff member contacts the supervising nurse (2)CORRECT—begin helping client prepare to move to a private room or in a room with same infection but no other infections; wear gloves when entering the client's room; change gloves after client contact; wash hands (3)priority is to place client on contact precautions (4)primary focus is to control or prevent the spread of the infection

A mother accidentally splashes ammonia into her 7-year-old son's eyes. Her neighbor, an LPN/LVN, is present and should IMMEDIATELY take which of the following actions? 1. Take the boy to the nearest ophthalmologist. 2. Clean the boy's eyes with a boric acid solution. 3. Flush the boy's eyes with lukewarm water. 4. Place patches over both of the boy's eyes.

Strategy: "IMMEDIATELY" indicates priority. (1) primary principle is to remove, neutralize, or dilute chemical as soon as possible; LPN/LVN should flush the child's eyes with water to dilute the chemical (2) use lukewarm water or normal saline; irrigate for 15 to 20 min; on the scene treatment is usually limited to using a non-chemically based solution; NSS is considered a basic solution that anyone can use for flushing the area (3) CORRECT—whenever a caustic or irrigating liquid is splashed into the eye, immediate irrigation with water is warranted; the shorter the delay, the less the eye tissue will be damaged as well as decreasing the period of suffering (4) rationale for covering eyes is to protect eyes from exposure; might cover after chemical has been diluted or removed

The LPN/LVN cares for a client in the neurological unit newly admitted for a cerebrovascular accident (CVA). The LPN/LVN notes the client sustained blunt trauma to the abdomen that was surgically repaired 18 days ago, and the client has been receiving peripheral parenteral nutrition (PPN) for 17 days. Which of the following actions by the LPN/LVN is MOST appropriate? 1. Read the chart to determine the area and size of the brain damage. 2. Assess the impact immobility had on the client's recovery from surgery. 3. Ask the physician about the client's rehabilitation potential. 4. Report to the supervising nurse the length of time the client has been receiving peripheral parenteral nutrition (PPN).

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) will help the staff determine the appropriate plan of care; priority is to address the PPN (2) immobility related to CVA more important than immobility related to surgery (3) determined by the rehabilitation team (4) CORRECT—PPN is utilized for periods less than 2 weeks because it can be damaging to the veins

In an outpatient clinic, the LPN/LVN contributes to the discharge planning of a client after an endoscopic retrograde cholangiopancreatography (ERCP) procedure. Which of the following instructions is MOST appropriate for this client? 1. Report diaphoresis, elevated temperature. 2. Drink cool liquids and gargle throat q 2 hours. 3. Inform client that oral cavity may feel dry. 4. Tell the client the dye ingested may cause diarrhea.

Strategy: "MOST appropriate" indicates discrimination may be required to answer the question. (1) CORRECT—indicative of septicemia related to cholangitis; tube is passed through oral cavity to the common bile duct to the pancreatic ducts for visualization of the surfaces (2) procedure may cause throat irritation; this can relieve the soreness; do not offer fluids until gag and cough reflexes return (3) because throat is sprayed with local anesthetic, aspiration is more likely; atropine may be administered to prevent aspiration of saliva (4) more commonly associated with oral cholecystogram

After making rounds, a health care provider writes an order for serum thyroxine level for a client receiving propylthiouracil (PTU) 100 mg po q 8 hours. Which of the following actions by the LPN/LVN is MOST appropriate? 1. Transcribe order. 2. Notify supervising nurse. 3. Review client health history. 4. Obtain vital signs.

Strategy: "MOST appropriate" indicates discrimination may be required to answer the question. (1) CORRECT—reduces thyroxine levels in clients with hyperthyroidism; the lab test would validate drug effectiveness; side effects include leucopenia, fever, rash, sore throat, and jaundice (2) dosage is correct; lab test is correct; independent LPN/LVN activity is appropriate; no need for consulting with supervisor (3) lab test matches hormone level altered by the disease (4) vital signs are altered by the increased hormone level but would not add to database to aid LPN/LVN in appropriate decision making

While assisting a client from the bed to the chair, the LPN/LVN accidentally dislodged a urinary catheter. Which of the following, if performed by the LPN/LVN, is MOST appropriate? 1. Document in detail the incident in the nurse's notes. 2. Complete an incident report and insert in client's chart. 3. Ask the supervising nurse about prophylactic antibiotics. 4. Complete incident report and submit to charge nurse.

Strategy: "MOST appropriate" indicates discrimination may be required to answer the question. (1) documentation entered in client's chart should be related to the client's needs; the details should be saved for the incident report (2) should not be included in the chart; is documentation of intra-agency quality control/quality improvement system (3) primary role of LPN/LVN is to document the incident; health care provider makes decision about prescribing medications (4) CORRECT—person involved in incident should enter description of incident, then forward to supervisor

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.

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

During a home appointment, a client informed the LPN/LVN that her gums bleed heavily for an hour after brushing her teeth. The client takes warfarin (Coumadin) 5 mg po daily. Which of the following statements by the LPN/LVN is MOST appropriate? 1. "Take half of the dosage in the morning and half in the evening." 2. "You need to use a toothbrush with very soft bristles." 3. "Until I can reach your physician, discontinue taking the drug." 4. "Are you bleeding that much after other types of injuries?"

Strategy: "MOST appropriate" indicates discrimination may be required to answer the question. (1) not appropriate to change physician's orders; warfarin (Coumadin) has a long half-life; splitting the dosage will not change the bleeding (2) even with firm bristles, bleeding time for anticoagulant therapy should not continue for 1 hour; normal clotting time during anticoagulant therapy is 18-37.5 seconds (3) CORRECT—need to consult with prescriber about the problem; bleeding is far above normal; warfarin (Coumadin) is an anticoagulant that is effective several days after ingestion ceases; antagonist is vitamin K (4) has enough information to make decision

The nurse cares for a 32-year-old client scheduled for a hysteroscopy. It is MOST appropriate for the LPN/LVN to take which of the following actions? 1. Determine the number of live births the client has experienced. 2. Provide clear liquids the morning of procedure. 3. Instruct client to avoid emptying bladder. 4. Assess the client's last menstrual period.

Strategy: "MOST appropriate" indicates discrimination may be required to answer the question. (1) not relevant to procedure; interior of uterus is viewed through transcervical endoscopy (2) because may be performed with general anesthesia, should remain NPO to prevent risk of aspiration (3) should empty bladder before procedure; distended bladder is easier to perforate (4) CORRECT—schedule about five days after completion of menstrual period, allows for better visualization of the interior of uterine wall; decreases risk of interruption of pregnancy

An adult client comes to the emergency room immediately after puncturing her foot with a dirty, rusty nail. The client's last tetanus shot was 6.5 years ago. Which of the following actions by the LPN/LVN is MOST appropriate? 1. Administer a tetanus booster. 2. Cleanse the wound. 3. Give typhoid booster. 4. Monitor for signs of lockjaw.

Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. (1)CORRECT—tetanus is a fatal disease caused by a bacterium that can live for a long time in soil and dirt; can enter the blood via wounds and affect the central nervous system; after a dirty wound, a tetanus toxoid booster is given to ensure protection against tetanus (2)cleansing the wound would be part of the basic care; because would not protect the client from a potentially fatal disease, is not the MOST appropriate (3)acute infectious disease caused by Salmonella typhi; would not meet client's current needs (4)manifestations of tetanus include opisthotonus, muscle rigidity, cramps, and muscle spasms; give tetanus toxoid to prevent the development of tetanus; not likely to develop during this time period

While keeping an appointment at a well-baby clinic, the mother of a 2-month-old infant reports to the LPN/LVN that the infant has been vomiting after every feeding. Which of the following interventions by the LPN/LVN is MOST appropriate? 1. Instruct the mother to withhold feedings and go to emergency room. 2. Compare the size of the infant to other siblings. 3. Decrease the length of intervals between feedings. 4. Decrease the size of the feedings.

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) CORRECT—pyloric stenosis is obstruction of the passageway from the stomach to the duodenum due to enlargement of the sphincter muscle; 8 weeks without complete retention of feedings places the infant at great risk; immediate health care is imperative (2) is utilized more to compare birth weights rather than weight at 2 months (3) more frequent feedings are appropriate when GI tract is irritated or inflamed (4) decreased size of feedings is appropriate when GI tract cannot tolerate large volumes of feedings; this situation is related to difficulty with an improperly functioning sphincter, which will probably require surgical alteration

A woman delivers a healthy, 8-lb, 2-oz boy. She asks the LPN/LVN how to care for the baby's "soft spot." It is MOST appropriate for the LPN/LVN to teach the mother about which of the following? 1. Do not touch the area until the bones harden. 2. Keep the area covered at all times. 3. If the soft spot bulges during coughing, notify clinic at once. 4. Except for gentle cleansing, avoid handling the area.

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) takes 12 to 18 months to close; would be appropriate to cleanse (2) because infants lose body heat from the head, should cover during cold weather; not necessary to keep area covered otherwise (3) coughing or crying can causes anterior fontanel to bulge (4) CORRECT—would be appropriate to cleanse without applying excessive pressure to the area

The LPN/LVN supervises care in a long-term care facility. A nursing assistant mentions to the LPN/LVN that he is experiencing an outbreak of genital herpes simplex. Which of the following responses by the LPN/LVN is MOST appropriate? 1. "Come to work as scheduled." 2. "Stay at home until the lesions have healed." 3. "How did you contract genital herpes?" 4. "Are you taking medication for the outbreak?"

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1.) CORRECT— no work restrictions for staff with outbreak of genital herpes (2.) not necessary; sexually transmitted disease; itching and soreness occur before erythema develops, followed by eroding vesicles (3.) not relevant (4.) LPN/LVN may want to follow up, but priority is informing staff member that he can work; treatment is oral acyclovir

The LPN/LVN supervises care for clients in a long-term care facility. The LPN/LVN receives a phone call from a nursing assistant saying that he has been diagnosed with active tuberculosis and has been receiving treatment for the tuberculosis. Which of the following responses by the LPN/LVN is MOST appropriate? 1. "You will never be able to take care of clients again." 2. "What are the results of the sputum acid-fast bacilli (AFB) smears?" 3. "Did any of your family contract TB?" 4. "Does your physician think that you can safely work?"

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1.) exclude from caring for clients until staff member is proven to be noninfectious (2.) CORRECT— able to work after three sputum acid-fast bacilli (AFB) smears are negative and the cough has resolved, and with documentation that staff member is taking medication (3.) not important at this time (4.) better question to ask is about the sputum acid-fast bacilli (AFB) smears

The LPN/LVN assists in the care of a client diagnosed with active pulmonary tuberculosis. The client is called to x-ray. Which of the following actions by the LPN/LVN is MOST appropriate? 1. Contact the physician. 2. Place a face mask on the client during transport. 3. Place a face mask on the staff transporting the client. 4. Contact x-ray to tell them the client has active tuberculosis.

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1.) no reason to contact the physician (2.) CORRECT— client should be placed in private room with monitored negative air pressure with 6 to 12 air changes per hour; place mask on client when outside the room (3.) priority is to prevent client from spreading the disease (4.) appropriate action; priority is to place mask on client

The LPN/LVN performs a home care visit on a client with a diagnosis of a right-sided cerebrovascular accident (CVA). The client's wife states that she is having frequent loose stools, and the physician diagnosed viral gastroenteritis. The LPN/LVN is MOST concerned if which of the following is observed? 1. The wife washes her hands frequently. 2. The wife drinks Gatorade. 3. The wife takes antibacterial medications. 4. The client utilizes the commode immediately after his wife.

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 wife uses commode, should be cleaned with cleanser such as chlorine bleach to prevent client developing gastroenteritis

Which of the following measures is MOST effective in protecting the nursing staff from harmful exposure to radiation when caring for a patient with a radiation implant? 1. Rotate the staff members assigned to the patient. 2. Wear a gown and mask when in contact with the patient. 3. Leave the patient's room at least every 10 minutes. 4. Place the patient in a room with a private bathroom.

Strategy: "MOST effective" indicates that discrimination may be required to answer the question. (1.) CORRECT— it is important to decrease the time and increase the distance when dealing with a patient with a radium implant; rotating the staff members will prevent excessive exposure to radiation while providing for the needs of a client on bedrest (2.) more appropriate for protection from microorganism contamination; gown and mask are not the MOST appropriate shields for protection against radiation exposure (3.) same nurse should not re-enter the room until all of the staff has assisted in management of the client's needs (4.) because the goal is to protect all occupants of the area from radiation exposure, client placed in a private room

The LPN/LVN cares for a client diagnosed with sickle cell crisis. The client's son comes to visit his father, and the LPN/LVN observes that the son has an upper respiratory infection. It is MOST important for the LPN/LVN to take which of the following actions? 1. Inform the son that he cannot visit his father. 2. Instruct the son to stand at least 6 feet away from his father. 3. Give the son a mask to wear when visiting his father. 4. Demonstrate to the son the correct way to put on a gown and gloves.

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) can visit his father but must wear a mask (2) son should wear a mask (3) CORRECT—every person entering the room should wash hands thoroughly; person with URI should wear a mask when entering the room (4) gown and gloves are not necessary

Following the placement of a long leg cast to stabilize a fractured tibia and fibula, the client is discharged from the emergency room. Five days later, the home care LPN/LVN conducts a follow-up visit. Which of the following instructions by the LPN/LVN is MOST important? 1. Notify health care provider if pain not relieved by analgesia. 2. Elevate cast on pillows and do not cover with bed linen 3. Use soft object to relieve itching inside the cast 4. Monitor the rubber tips on the ends of the crutches.

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) immediately after cast applied, important to assess for blueness, pain, numbness, tingling; may indicate neurovascular compromise (2) promotes cast drying first 24 to 72 hours; not appropriate several days later (3) should not insert anything inside the cast (4) CORRECT—prevents or reduces risk of falling; crutch ends are smooth, and there is increased risk of falling if tips are also smooth

During a home appointment with a client diagnosed with type 1 diabetes, the client tells the LPN/LVN that he feels irritable, and has tremors and blurred vision after exercising. It is MOST important for the LPN/LVN to include which of the following instructions? 1. Take insulin before exercising. 2. Eat an appropriate snack after exercising. 3. Plan a two-hour rest period after exercising. 4. Avoid strenuous exercising immediately after meals.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) administering insulin would compound the risk of hypoglycemia (2) CORRECT—hypoglycemia can occur hours after exercise; a snack would provide necessary glucose to prevent a drop in blood sugar (3) glucose levels fluctuate in relation to exercise that has occurred not in relation to rest after exercise (4) exercising immediately after meals can prevent the development of hypoglycemia

The LPN/LVN assists in the instruction of a client diagnosed with hepatitis A and his family about how to prevent the spread of the disease. It is MOST important for the LPN/LVN to include which of the following instructions? 1. "Do not share eating utensils and drinking glasses with the client." 2. "Do not come in contact with the client's blood." 3. "No one in this family should donate blood during the next year." 4. "You do not have to take any precautions because you have been treated with gamma globulin."

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) CORRECT—hepatitis A is spread by fecal-oral route; client should wash hands before eating and after using the toilet; client infected with hepatitis A should not prepare food for the family (2) hepatitis A spread by fecal-oral route (3) family can give blood; client cannot (4) good hygiene required; gamma globulin increases the resistance to the infection; hygiene reduces the degree of exposure

Following an endoscopic retrograde cholangiopancreatography (ERCP), it is MOST important for the LPN/LVN to report which of the following signs/symptoms immediately? 1. Severe abdominal pain, nausea/vomiting. 2. Drowsiness, confusion, amnesia. 3. Sore throat with blood-streaked mucus. 4. Pain during irrigation of catheter.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) CORRECT—indicative of ERCP-induced pancreatitis; tube is passed through oral cavity to the common bile duct to the pancreatic ducts for visualization of the surfaces (2) client is sedated for procedure; these signs/symptoms common (3) throat may be irritated during procedure; blood-streaked mucus is not a sign/symptom of risk to client (4) because it is inserted into small areas, catheter is not irrigated during procedure; catheter is removed following procedure

Because a client is admitted to an outpatient surgical clinic for an arthroscopic examination, it is MOST important for the LPN/LVN to take which of the following actions? 1. Inspect overlying skin for signs/symptoms of infection. 2. Determine the type of joint inflammation. 3. Place client in supine position on operating table. 4. Assess prior use of corticosteriods.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) CORRECT—infections near the puncture site can place the client at risk for sepsis; because of the limited vascularity, bone infections are very difficult to manage (2) except for ankylosis, an arthroscopic examination can be performed on clients without regard to nature of the problem; assessment does not fall within the area of practice for the LPN/LVN (3) is proper position for procedure; assessment of site needs to be performed first (4) can delay healing, but risk of direct contact of microorganisms to site takes priority

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.

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

Following a cystoscopy, the LPN/LVN admits the client to the medical unit. It is MOST important for the LPN/LVN to take which of the following actions? 1. Encourage the client to ingest the prescribed prn laxative. 2. Teach client how to care for the urinary catheter. 3. Assess for fever, chills, and increased pulse. 4. Apply warm, moist heat to lower abdomen.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) cystoscopy is direct visualization by the cystoscope inserted into the bladder; more appropriate to take laxative if surgery was performed during procedure; prevents straining because of constipation (2) catheter not commonly left in place (3) CORRECT—urinary tract is sterile and highly susceptible to bacterial invasion; immediate treatment is imperative; also assess for abdominal distension, urinary frequency (4) promotes muscle relaxation related to bladder spasms; does not take precedence over risk of infection

A client is scheduled for a liver biopsy this afternoon. It is MOST important for the LPN/LVN to implement which of the following 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.

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

While a client is traveling through the central plains states, a car accident resulted in blunt trauma to the client's lower abdomen. After the trauma surgeon schedules a laparoscopic examination, it is MOST important for the LPN/LVN to confirm which of the following assessment information? 1. A description of how the accident occurred. 2. The number and type of previous surgeries experienced by the client. 3. The measurement of the client's abdominal girth. 4. Indications of post-traumatic syndrome.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) not relevant to situation; client's clinical profile is best source of information (2) CORRECT—multiple surgical procedures can result in adhesions between the viscera and the abdominal wall, decreasing safe access to abdominal cavity; is safe to request repeated report of information in situation where client is not known by the staff and when the client is enduring intense stress (3) results of laparoscopic procedure would determine the need for this procedure (4) not likely to occur this close to the traumatic experience; syndrome is long-term emotional response to trauma

The LPN/LVN cares for a client 30 minutes after a paracentesis. It is MOST important for the LPN/LVN to provide the nursing assistants with which of the following instructions? 1. "Administer low-volume enema." 2. "If drainage continues, place colostomy bag over site." 3. "Measure client's intake and output (I/O)." 4. "Report bleeding or continued drainage from site."

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) paracentesis is needle aspiration of fluid in abdominal cavity; empty bladder immediately before procedure; because of reduced fluid volume, need to rest immediately after procedure; enema administration not required (2) assess for shock and/or infection; check puncture site for bleeding and leakage (3) volume depletion can occur, as well as the outcomes of third spacing; because not related directly to procedure, lacks immediacy associated with maintaining puncture site (4) CORRECT—may need suture or pressure dressing applied; covering of wound site can reduce the risk of infection

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? 1. Explain that during the procedure, the physician may dilate hardened arteries. 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. 4. Review with the client online illustrations of the procedure.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) plaques may be compressed by expanding the catheter inserted in the blood vessels; may not recall information several days later (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 (4) provides client with information about the procedure; may or may not reduce anxiety; priority is preventing or reducing risk of infection

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 of the following client instructions? 1. Do not exercise if the blood sugar 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

A health care provider prescribes levothyroxine (Synthroid) 50 mcg po daily for an elderly client. It is MOST important for the LVN/LPN to include which of the following instructions to the client? 1. Ingest medication with food. 2. Report for serum thyroxine level after 7 days. 3. Return after 10 days for thorough cardiac workup. 4. Avoid excessive exercise.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) taking on empty stomach is recommended; levothyroxine (Synthroid) is hormone replacement; side effects include nervousness, tremors, insomnia, tachycardia, palpitations, dysrhythmias, and angina (2) therapeutic effectiveness occurs after several weeks (3) because drug increases basal metabolic rate (BMR), it can have adverse effects such as tachycardia, dysrhythmia, hypertension; testing is recommended before initiating treatment; is especially true with older adults (4) CORRECT—stressors such as exercise, infection, or surgery can cause a life-threatening exacerbation; onset of drug is 3-4 weeks; should wait until drug becomes effective

The LPN/LVN supervises care for clients in a long-term care facility. The LPN/LVN receives a phone call from a nursing assistant saying that she can't come to work because she has been vomiting. Which of the following responses by the LPN/LVN is MOST important? 1. "You can come to work if you practice good hand hygiene." 2. "Do you have an elevated temperature?" 3. "Do you have diarrhea?" 4. "Stay home until your symptoms have subsided."

Strategy: "MOST important" indicates priority. (1.) exclude from work until symptoms resolve (2.) exclude from work if any symptoms of acute gastrointestinal illness (nausea, vomiting, elevated temp, abdominal pain) (3.) exclude from work if any symptoms of acute gastrointestinal illness (nausea, vomiting, elevated temp, abdominal pain) (4.) CORRECT— restrict from client care, the client's environment, and food handling until symptoms have resolved

The LPN/LVN supervises care in a long-term care facility. A nursing assistant contacts the LPN/LVN to report that she has just been diagnosed with hepatitis A. Which of the following responses by the LPN/LVN is MOST important? 1. "How are you feeling?" 2. "Are you jaundiced?" 3. "You can come back to work in 7 days." 4. "How do you think you contracted hepatitis A?"

Strategy: "MOST important" indicates priority. (1.) symptoms include jaundice, anorexia, right upper quadrant pain, clay-colored stools, and tea-colored urine (2.) one of the indications; treatment includes bedrest, diet low in fat and high in calories, carbohydrates, and protein; no alcohol (3.) CORRECT— restrict from patient care, contact with patient's environment, and food handling for 1 week after onset of illness (4.) not the LPN/LVN's priority

The LPN/LVN implements the discharge plan initiated by the RN for a client diagnosed with active tuberculosis. Which of the following instructions is MOST important for the LPN/LVN to include? 1. "Come to the clinic monthly for tine test monitoring and to recheck your chest x-ray." 2. "Return to the clinic if you experience any side effects from the medications." 3. "Come to the clinic weekly for your INH injections." 4. "Come to the clinic monthly to check the effects of the medications you are taking."

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1) tine test is read after 72 hours; will always be positive; should monitor physical condition, nutritional status, and client's compliance with medication regimen (2) true statement, but client requires ongoing assessment; should come to clinic regularly, not just when experiencing side effects (3) medication is taken daily (4) CORRECT—having the client actually come to the clinic monthly will provide opportunities assessment of signs/symptoms of hepatitis, such as jaundice; also provides opportunity to reinforce necessity of taking medication for several months

While a client is being treated for a wound infection, it is MOST important for the LPN/LVN to routinely perform which of the following actions? 1. Check and record the client's temperature. 2. Send samples of wound drainage for culture. 3. Assess the perfusion in the area. 4. Determine the results of the blood culture.

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1)CORRECT—a client with a wound infection is at risk for bacteremia or other complications, such as glomerulonephritis (2)treatment will not be initiated until culture is obtained (3)assess for indication of inflammation, e.g., redness and tenderness; adequate perfusion is needed for wound healing; protecting the client from further injury or damage is MOST important (4)information should be communicated to physician as soon as possible for appropriate prescription of antibiotics

A client is treated for an infection involving the left eye. The prescribed medications include eyedrops and antibiotic ointment. When applying the antibiotic ointment, it is MOST important for the LPN/LVN to take which of the following actions? 1. Administer the medication precisely at the ordered time. 2. Use a new medication container each time a dose is administered. 3. Avoid touching the eye with the tip of the tube. 4. Apply a generous amount to the inner canthus.

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1.) not unique to this particular drug; principle applies to all drugs (2.) appropriate to use multiple doses from the same tube (3.) CORRECT—important to maintain aseptic technique and avoid cross-contamination; in addition to maintaining asepsis, not touching the eye with the tube will avoid corneal irritation (4.) pull lower lid downward toward the cheekbone, creating a pocket; squeeze a small amount of ointment in the pocket; to promote absorption, administer eyedrops first; ointment is oil-based

The LPN/LVN assesses a client soon after a percutaneous transluminal coronary angioplasty (PTCA). The LPN/LVN discovers that the peripheral pulse on the affected side is discernible only with a Doppler. It is MOST important for the LPN/LVN to include which of the following instructions to the nursing assistants? 1. Set up safety precautions for this client. 2. Position the client in the prone position. 3. Remove food and water from room. 4. Measure intake and output (I/O).

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1) PTCA is procedure to dilate occluded coronary artery by inserting a balloon-tipped catheter under fluoroscopy to compress plaque against the artery wall; client will be on bedrest after procedure; no obvious safety risks (2) supine is best position; need to frequently assess puncture site, as well as cardiac assessment (3) CORRECT—indicates clot formation around sheath; surgical release of obstruction is likely (4) fluid balance after procedure helps determine cardiac output as well as renal function; primary focus is on possible preparation of client for impending surgery

To provide safety for the clients, the LPN/LVN at an outpatient pediatric clinic prepares for the administration of diphtheria, pertussis, and typhoid (DPT) vaccine. It is MOST important for the LPN/LVN to place which of the following item at each station? 1. Band-Aids of various sizes. 2. Injectable epinephrine 1:1,000. 3. Individually packaged orange juice. 4. Padded tongue blades.

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1) is administered IM and may need Band-Aids; bleeding will not be life-threatening (2) CORRECT—proper management of a major allergic reaction would require immediate injection of epinephrine (3) infants may have allergy to orange juice (4) seizures are rare; do not utilize a padded tongue blade if client has a seizure

The parents are concerned because their 3-year-old boy diagnosed with hemophilia is constantly running and jumping. It is MOST important for the LPN/LVN to offer the parents which of the following information? 1. Help parents understand which behaviors are normal for the child's age. 2. Provide quieter activities for the child, such as computer games. 3. Purchase protective devices such as headgear and kneepads. 4. Should bleeding occur, apply firm pressure.

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1) parents need assistance on how to meet the child's needs without putting him at risk (2) needs to be able to perform normal tasks for his age group (3) CORRECT—will allow child to perform developmental tasks without being at risk for injury (4) gentle pressure is more appropriate; firm pressure would increase or prolong bleeding

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. 2. Encourage the clients to cough and deep-breathe at regular intervals. 3. Administer the influenza vaccine to all staff members. 4. Encourage staff to stay home if they have symptoms of the flu.

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 (2.) helps decrease secretions in clients' lungs; priority is to prevent the staff from developing influenza (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 (4.) if febrile, exclude from care

An 18-month-old toddler with cystic fibrosis is admitted to the hospital with a respiratory infection. One of the MOST significant nursing interventions the LPN/LVN will need to implement includes which of the following? 1. Assist with meals. 2. Report sodium levels. 3. Monitor liver enzymes. 4. Assist in maintaining growth and development.

Strategy: "MOST significant" indicates that discrimination may be required to answer the question. (1) will have difficulty with metabolism of nutrients because of pancreatic damage resulting in reduced levels of pancreatic enzymes; not priority (2) CORRECT—sodium losses are significant with this disease; cystic fibrosis is an autosomal recessive trait with generalized involvement of the exocrine glands, resulting in altered viscosity of mucus-secreting glands (3) liver enzymes do not change (4) chronic illness and hospitalization can interfere with growth and development, but physiological needs should be met first; developmental needs should be a part of the nursing care plan

Immediately before shift report, the reporting LPN/LVN reads an order for levothyroxine 100 mcg po daily for a client diagnosed with Graves' disease. Which of the following actions should the LPN/LVN take NEXT? 1. Transcribe according into medication administration system. 2. Inform the next shift that the order needs to be reviewed. 3. Consult with the reporting charge nurse. 4. Refer to textbook for appropriate dosage.

Strategy: "NEXT" indicates priority. (1) Graves' disease is hyperthyroidism; levothyroxine (Synthroid) is a thyroid replacement administered for hypothyroidism; order does not meet implementation criteria, which includes a match between health problem and prescribed drug (2) verbal transfer of information increases the risks to the client; a high percentage of errors occurs during shift change (3) CORRECT— Graves' disease is hyperthyroidism; levothyroxine (Synthroid) is a thyroid replacement administered for hypothyroidism; addressing before the reporting nurse leaves is less likely to place client at risk; many errors occur during shift change (4) dosage appropriate for hypothyroidism

The home care LPN/LVN provides care for a client with a fractured humerus due to a fall in the home. Which of the following observations requires an immediate intervention? 1. The bathroom is equipped with grab bars. 2. Throw rugs have been removed. 3. The client ambulates wearing socks. 4. The stairs are well lighted.

Strategy: "Requires an immediate intervention" indicates something is wrong. (1)considered safe environmental structures (2)because clients can trip over the edges of rugs or rugs can slip, resulting in accidental injuries, throw rugs should have nonskid backing or be removed (3)CORRECT—should wear shoes or slippers with nonskid surfaces (4)ensure that there is adequate lighting on stairs; many falls at the top step and at the bottom step of stairs

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/mm3. 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.

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

The LPN/LVN observes a student nurse (RN) add IV solution to the existing tubing in the upper arm of an elderly client. The LPN/LVN should intervene if which of the following is observed? 1. The student matches the bag label with the original orders. 2. The student starts to mark the time on the IV bag with a permanent marker. 3. The student inserts the tubing with the bag hanging. 4. The student checks the venipuncture insertion site.

Strategy: "Should intervene" indicates a complication. (1) use smallest gauge needle possible (24 and 26) in older clients (2) CORRECT—can contaminate the solution; use time tape (3) because of superficial veins of older adults, angle insertion at 5 to 15 degrees (4) should check the site before adding the solution to the tubing; if is infiltrated, prescriber may choose to discontinue

The LPN/LVN cares for clients in the long-term care facility. The LPN/LVN observes an unlicensed assistive personnel assist a client out of bed and ambulate to the bathroom. The LPN/LVN should intervene if which of the following is observed? 1. The unlicensed assistive personnel places soft, hand-knitted socks on the client. 2. The unlicensed assistive personnel elevates the head of the bed before helping the client sit at the side of the bed. 3. The unlicensed assistive personnel locks the wheels of the bed before helping the client out of bed. 4. The unlicensed assistive personnel detaches the urinary drainage bag from the bed.

Strategy: "Should intervene" indicates an incorrect action. (1.) CORRECT— client should wear shoes that maximize traction to prevent falling (2.) appropriate action; client will use less energy; reduces risks of staff injuries (3.) prevents falling; clients often use the bed as an anchor or support while getting out of bed (4.) prevents accident dislodgement of the catheter

The home care LPN/LVN visits a client diagnosed with AIDS. The LPN/LVN should intervene if which of the following is observed? 1. The client places used "sharps" in a coffee can. 2. The bathroom is disinfected with a 1:10 solution of household bleach. 3. Soiled linens are placed in a laundry hamper. 4. The family washes the dishes in the dishwasher.

Strategy: "Should intervene" indicates an incorrect action. (1) appropriate action; when can is full, add 1:10 bleach solution (1 part bleach, 10 parts water); seal container with tape and place in paper bag; dispose in regular trash (2) clean all surfaces with household cleaner, then disinfect with 1:10 bleach solution (3) CORRECT—keep soiled laundry in a plastic bag (4) appropriate action

The LPN/LVN observes a staff member prepare to leave the room of a client on droplet precautions. The LPN/LVN should intervene if which of the following is observed? 1. The staff member removes the gloves by pulling off the gloves inside out. 2. The staff member holds onto the outer surface of the facemask while pulling mask away from face. 3. The staff member unties the gown and removes it without touching the outside of the gown. 4. The staff member washes her/his hands for 15 seconds.

Strategy: "Should intervene" indicates an incorrect action. (1)appropriate action; do not touch outside of glove (2)CORRECT—do not touch outer surface of mask; untie top mask string and then bottom string; pull mask away from face and drop into trash receptacle (3)appropriate action; goal is to restrict contaminant to possible exposed areas (4)appropriate action; handwashing is the BEST preventive measure for controlling the spread of infection

The LPN/LVN supervises care of clients in a long-term care facility. The LPN/LVN observes a client in a Posey restraint. The LPN/LVN should intervene if which of the following is observed? 1. The nursing assistant attaches the restraints to the bed frame using a quick-release tie. 2. The nursing assistant leaves the side rail down on the side of the client contact. 3. The nursing assistant removes the restraints every 2 hours. 4. The nursing assistant places the bed in the low position.

Strategy: "Should intervene" indicates an incorrect action. (1.) appropriate action; attaching restraint to side rail may cause injury to client when side rail is lowered (2.) CORRECT— place both side rails in elevated position; keep client's entire body on mattress (3.) appropriate action; change client's position, toilet client, offer food and fluids (4.) appropriate action; reduces chance of injury if client falls; lock wheels

The LPN/LVN assists in the care of a client who has a radioactive cobalt implantation. The LPN/LVN should intervene in which of the following situations? 1. The nursing assistant gives the client a pan of water. 2. A visitor suggests that the client request medication for restlessness. 3. The client's mother gives the client a warm embrace. 4. The staff wear dosimeter film badges when interacting with the client.

Strategy: "Should intervene" indicates incorrect action. (1.) encourage client to perform own care; nurse should spend limited time in the client's room (2.) appropriate for visitor to make suggestion; clients spend time alone on bedrest and can become restless; often will share feelings with visitors and not with the nurse (3.) CORRECT— client on bedrest while implant is in place; visitors should limit time spent in the client's room; do not touch, stand close to, or in line with radioactive source (4.) dosimeter film badge measures amount of exposure to radiation; determines if it is safe for the employee to enter room; save all dressing and bed linens until radiation source is removed, then discard dressings and linens as usual

After the LPN/LVN administers the MMR vaccine to a toddler, the LPN/LVN instructs the parents that which of the following adverse reactions is MOST likely to occur? 1. Fever. 2. Convulsions. 3. High-pitched cry. 4. Paralysis.

Strategy: Think about each answer. (1) CORRECT—adverse-effects fever is often seen in 5 to 15% of children after the MMR vaccination (2) serious side effect of pertussis in diphtheria, pertussis, tetanus (DPT) (3) vaccination is combined with diphtheria and tetanus administration, but persistent crying is associated with pertussis; seen in small percentage of the population (4) rare, but may occur with IPV

In a long-term care facility, the LPN/LVN supervises care of a client who is immunocompromised. The LPN/LVN should intervene if which of the following is observed? 1. A staff member leaves the blood pressure cuff in the client's room. 2. A staff member brings fresh flowers to the client. 3. A staff member encourages the client to cough and deep-breathe. 4. A staff member performs hand hygiene before caring for the client.

Strategy: "Should intervene" indicates something is wrong. (1.) appropriate behavior; limits client's exposure to organisms (2.) CORRECT— do not expose client to potted plants or fresh flowers, or allow client to dig in dirt (3.) decreases secretions in the client's lungs and decreases chance for infection (4.) appropriate behavior; perform hand hygiene before and after caring for the client

The lead nurse conducts a teaching session about gonorrhea. The LPN/LVN reports to the lead nurse that teaching is effective because a client states which of the following? 1. "I've heard that having gonorrhea can make you unable to have children." 2. "They say this disease can affect your brain and make you go crazy." 3. "I've heard you can't get rid of gonorrhea. It comes back over and over again." 4. "My mother said that you need to have cesarean deliveries after this infection."

Strategy: "Teaching is effective" indicates correct information. (1.) CORRECT— gonorrhea causes pelvic inflammatory disease, one of the most common causes of sterility; gonorrhea is treated with antibiotics (2.) central nervous system involvement occurs with late syphilis (3.) episodes are self-limiting with ingestion of antibiotics; should avoid sexual activity until infection is cured; is more indicative of genital herpes (4.) with treatment, there is no need for cesarean deliveries; topical antibiotics are utilized to decrease potential for conjunctivitis; without treatment, gonorrhea can cause preterm labor, resulting in premature birth, premature rupture of membranes, or postpartum endometritis

The LPN/LVN instructs a nursing assistant about proper body mechanics. The LPN/LVN determines teaching is successful if which of the following is observed? 1. The nursing assistant bends at the waist when lifting objects. 2. The nursing assistant carries objects by holding them away from the body. 3. The nursing assistant bends the knees when lifting objects. 4. The nursing assistant leans forward when lifting objects.

Strategy: "Teaching is successful" indicates correct behavior. (1)should not use back to lift; should use arms and legs (2)should carry objects close to the body while keeping the weight close to the lifter's center of gravity (3)CORRECT—maintains center of gravity and allows the legs muscles to do the lifting (4)keep trunk erect, and do not twist

An LPN/LVN participates in the discharge planning of a client post myocardial infarction. When instructing the client about exercise, which of the following instructions takes priority? 1. Take a cell phone with you when you walk alone. 2. If cardiovascular signs/symptoms occur during exercise, take a break. 3. The goal of progressive exercises is to increase the resting heart rate. 4. The cardiac rehabilitation program focuses solely on the client's needs.

Strategy: Determine the outcome of each answer. (1) CORRECT—because potential of client's cardiac reserve is not known, should have some form of communication in case a problem occurs (2) should notify health care system; adjustment of program may be needed (3) goal is to decrease resting heart rate, as well as the response to activity (4) program focuses on the family unit

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.

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

Several days after a nonimmunized college student is exposed to varicella, the student begins experiencing severe left eye pain. That evening the student goes to the student health service. Because the school nurse is not available, the LPN/LVN assisting the school health nurse should take which of the following actions? 1. Ask if the client has had a blow to the area with in the last 24 hours. 2. Ask if the person with the varicella had a generalized rash. 3. Recommend that the student go to the local emergency room. 4. Examine the student for verification or nonverification of varicella.

Strategy: Determine the outcome of each answer. Is it desired? (1) visible evidence would indicate if trauma to the area had occurred (2) could acquire disease without being exposed to drainage from a rash (3) CORRECT—severe eye pain is sufficient to report for emergency care; varicella or shingles can develop along the facial nerve; cannot offer care for severe eye pain; further assessment only delays treatment by agency that could provide the care (4) primary problem is the severe eye pain; could perform regarding development of varicella at a later time

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.

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 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.

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

A client had a subtotal thyroidectomy this morning. Because of the risk for damage to the parathyroid gland, the LPN/PVN performs which of the following? 1. Places a tracheotomy tray at the bedside. 2. Places calcium gluconate at the bedside. 3. Ensures adequate organ meats are included in the diet. 4. Instructs the nursing assistants to force fluids.

Strategy: Determine the outcome of each answer. Is it desired? (1.) parathyroid damage does place client at risk for an impaired airway (2.) CORRECT— damage to the parathyroids may cause a decrease in serum calcium that would be manifested by numbness; also causes tetany, seizures, confusion, Trousseau's sign, and Chvostek's sign (3.) because primary nutritional value of organ meats is protein and iron, they do not contribute directly to increasing calcium levels (4.) need to force fluids because of the increased demand related to the inflammatory process associated with response to injury

The LPN/LVN instructs a client with an infection in her left eye about how to protect her vision from further injury. It is MOST important for the LPN/LVN to include which of the following instructions? 1. Touch the eyeball gently with medication droppers. 2. Provide eye care without putting pressure on the eye. 3. Prevent cross-contamination between the eyes. 4. Cleanse eyes inside and outside using a different tissue.

Strategy: Determine the outcome of each answer. Is it desired? (1.) should avoid touching eyeball with tips of containers; can cause injury and contaminates container; eye tissue is microorganism-free (2.) support hand on bony prominences of the face when instilling eyedrops or performing eye care (3.) CORRECT—measures to meet this goal include keeping hands away from the eyes, always washing the hands before and after eye care, and treating each eye separately even if there is an infection in both; the less infected eye should be treated first (4.) direct cleansing of actual eye tissue is done using irrigation; tissue can irritate and leave debris on eye tissue; would be painful and can cause injury

The LPN/LVN assists the health care provider to prepare a client diagnosed with rheumatoid arthritis for a pharmacologic stress test. The client is to receive dipyridamole (Persantine). To reverse the effects of dipyridamole (Persantine), the LPN/LVN should have which of the following medications available? 1. Dobutamine (Dobutrex). 2. Epinephrine (Adrenalin). 3. Aminophyllin (Theophylline). 4. Warfarin (Coumadin).

Strategy: Recall the action of each drug. (1) because it stimulates heart function, can be used to mimic the effects of exercise (2) is a catecholamine, hence it results in sympathetic stimulation, which results in tachycardia and increased O2 consumption (3) CORRECT—reverses the function of dipyridamole (Persantine) by reducing cardiac stimulation; if client is disabled and not able to perform the exercise required for a stress test, vasodilating agents are given to mimic the effects of exercise; dipyridamole (Persantine) is an anti-platelet agent (4) warfarin (Coumadin) increases prothrombin time; dipyridamole (Persantine) decreases platelet aggregation; would result in increased risk of bleeding; would not reverse the cardiac effects of dipyridamole (Persantine)

The LPN/LVN understands that which of the following is the CHIEF purpose of continuous bladder irrigation (CBI) after a transurethral resection of the prostate (TURP)? 1. Provide fluid replacement. 2. Infuse medications. 3. Increase urinary bladder capacity. 4. Prevent clot formation.

Strategy: Think about each answer and how it relates to continuous bladder irrigation. (1) fluids will be replaced orally or with an IV (2) except for prophylactic antibiotics, medications are rarely administered through this route (3) bladder capacity not usually a problem; because there is a constant outflow of the solution, would not be an effective method for dilating the bladder (4) CORRECT—chief purpose of constant irrigation is to keep the bladder free from clots that would block the drainage of urine; blood is excellent medium for infection; keeping the bladder free of blood or blood clots reduces the risk of infection; prophylactic antibiotics to prevent infection are sometimes infused via the three-way catheter

The LPN/LVN reviews charts on the unit. The LPN/LVN notices that a client has hyperglycemia, hypocalcemia, and hyperkalemia. The LPN/LVN notifies the supervising nurse of the possible need for which of the following? 1. Blood urea nitrogen (BUN), creatinine. 2. Bilirubin, alanine aminotransferase (ALT). 3. Measurement of hourly intake and output. 4. Complete blood count (CBC).

Strategy: Think about each answer and how it relates to the lab values. (1) CORRECT—indicative of renal failure; kidneys are unable to retain calcium and unable to excrete potassium; renal damage is commonly associated with diabetes mellitus (2) fluctuation in both are associated with liver failure; ALT is also associated with heart disease (3) intake/output needs to be measured but not necessarily hourly; would not provide the specific data provided by BUN and creatinine (4) erythropoietin production can result in anemia; CBC does not provide adequate information needed for diagnosis

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.

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

Which of the following routes of administration should the LPN/LVN use when administering a Mantoux test? 1. Intradermal injection. 2. Subcutaneous injection. 3. Local implantation. 4. Intramuscular injection.

Strategy: Think about each answer. (1) CORRECT—this is the route to be used for the Mantoux test; the substance used in the Mantouxtest is the PPD, or purified protein derivative; a local reaction occurs if the person has been sensitized to the tuberculosis bacteria; positive reaction is an area of induration (hard area under the skin) of 10 mm (2) if administered subQ, may result in a negative reaction; induration not likely to occur if administered subQ (3) goal is to expose client to minimum dosage to cause immune response; implantation of drugs is usually to provide exposure to circulatory system in order to gain access to a target tissue (4) medication inserted into the muscle gains access to circulatory system to distribute medication throughout the system or to a target tissue; this is not the goal of skin testing

The 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.

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

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? 1. Cereals. 2. Vegetables. 3. Fruits. 4. Eggs.

Strategy: Think about each answer. (1) first solid introduced at about 4-6 months; rice cereal usually first food due to easy digestibility and low allergenic potential (2) offer vegetables pureed; usually introduced after fruits; introduce a new food every 4-7 days to identify allergies (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

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 of the following statements 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." 4. "I have a rash."

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 (4) syphilis causes copper-colored rash on palms and soles

The LPN/LVN contributes to the teaching of a client diagnosed with tuberculosis. The LPN/LVN explains that tuberculosis is caused by which of the following? 1. A virus. 2. Poor sanitation. 3. Poor nutrition. 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 identifies that which of the following clients is MOST likely to have latex hypersensitivity? 1. A client diagnosed with asthma. 2. A client diagnosed with psoriasis. 3. A client diagnosed with spina bifida. 4. A client diagnosed with AIDS.

Strategy: Think about each answer. (1) not a risk factor for latex hypersensitivity (2) not a risk factor for latex hypersensitivity (3) CORRECT—serious health hazard for children with spina bifida due to repeated exposure; also at risk are health care workers and people who routinely use latex condoms; reaction can range from contact dermatitis to anaphylaxis (4) not a risk factor for latex hypersensitivity

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.

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 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.

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

It is important for the LPN/LVN to observe early parent-infant interaction for which of the following? 1. Proper parenting skills. 2. Healthy or pathological relationships. 3. Normal neurological functioning of the infant. 4. Parental knowledge of the infant's behavioral responses.

Strategy: Think about each answer. (1) proper parenting skills are important, but LPN/LVN should assess the parent-child interaction (2) CORRECT—observing the parents' behavioral responses to their newborn, including holding and interacting with the infant, gives some indication of a healthy or pathological response to the child; early observations by the LPN/LVN may also be used to identify infants at risk due to parental isolation, financial stress, or parental illness; referral to appropriate follow-up service may help lead to the establishment of a healthy parent-child relationship (3) not a part of the parent-infant interaction (4) appropriate, but assessing the parent-child interaction is most important

The LPN/LVN cares for a client who is immunosuppressed due to chemotherapy. The LPN/LVN determines that the care of this client is appropriate if which of the following is observed? 1. The nursing assistant obtains the client's vital signs every 8 hours. 2. The client is placed in a room with a client admitted with ulcerative colitis. 3. The nursing assistant washes her hands prior to changing the client's bed linens. 4. The staff brings in blood pressure equipment to obtain the client's blood pressure.

Strategy: Think about each answer. (1) vital signs should be monitored every 4 hours; report any change in temperature (2) should be placed in private room (3) CORRECT—wash hands before touching client or any object in client's room (4) keep frequently used equipment in the client's room

The LPN/LVN understands that which of these factors is the most likely source of delta hepatitis? 1. Eating infected shellfish. 2. Overly exerting oneself. 3. Practicing poor hygiene. 4. Receiving a blood transfusion.

Strategy: Think about each answer. (1) will cause hepatitis A (2) exertion will not cause hepatitis; clients do require frequent rest to promote healing of the liver (3) can cause spread of hepatitis A and hepatitis E (4) CORRECT—hepatitis D co-infects with hepatitis B; spread by contact with blood and body fluids

The LPN/LVN observes a staff member enter the client's room wearing a protective respiratory device. The staff member is probably caring for a client with which of the following diagnoses? 1. Tuberculosis. 2. Mumps. 3. Vancomycin-resistant enterococci (VRE). 4. Pneumonia.

Strategy: Think about each answer. (1)CORRECT—acid-fast bacillus has developed a resistance to commonly prescribed drugs; devices are specially fitted to prevent the spreading of the disease to clients and other staff members as well as within the community (2)droplet precautions; used with pathogens transmitted by infectious droplets; private room or with client with like infection; maintain spacial separation of three feet; may keep door open (3)contact precautions; place client in private room or with client with same infection; wear clean gloves when entering the client's room; change gloves after client contact; wash hands (4)droplet precautions

A nurse with a strong interest in reducing the spread of HIV/AIDS opens a community health agency. The LPN/LVN works alongside the nurse to reduce the spread of AIDS in the community. The LPN/LVN identifies which of the following elements as MOST likely to significantly reduce the spread of HIV/AIDS? 1. High-school anti-drug program, free condoms. 2. Day care for underprivileged children. 3. Programs to improve parent/child relations. 4. Implement sex education in elementary schools.

Strategy: Think about each answer. (1.) CORRECT— 20% of clients with HIV/AIDS abused drugs and shared needles as adolescents; a high percentage of this group engaged in unprotected sex with same-sex partners; because AIDS does not appear until 8 to 10 years later, data do not indicate that HIV/AIDS is an adolescent problem; programs to reduce exposure to HIV/AIDS in adolescents could reduce the spread of the disease among an unidentified population (2.) increased numbers of HIV/AIDS victims are poverty-stricken; day care could provide opportunity for education or employment which would reduce the poverty level; would not directly decrease exposure (3.) improved communication between parents and children can improve their relationships, which can result in less drug abuse and elicit safe sexual activity that can decrease the spread of HIV/AIDS; does not strike at the heart of the issue as addressing the particular population MOST at risk (4.) sex education in elementary schools can reduce the spread of HIV/AIDS but does not directly address the most at-risk population

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.

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

The LPN/LVN cares for a client diagnosed with meningococcal pneumonia. 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.

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 cares for a client diagnosed with suspected Haemophilus influenzae 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.

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 cares for a client diagnosed with a wound that is infected with multidrug-resistant organisms. 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.

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.) droplet precautions used for clients who have illness that is transmitted by large particle droplets (4.) CORRECT— 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 cares for a client diagnosed with pediculosis. 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.

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.) droplet precautions used for clients who have illness that is transmitted by large particle droplets (4.) CORRECT— 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 understands that the physician is MOST likely to prescribe which of the following drugs for a client diagnosed with gonorrhea? 1. Amphotericin B deoxycholate (Fungizone) IV daily. 2. Penicillin G benzathine intramuscularly in divided doses once a week. 3. Ceftriaxone (Rocephin) IM plus doxycycline (Vibramycin) for 7 days by mouth. 4. Ampicillin by mouth.

Strategy: Think about each answer. (1.) is antifungal antibiotic; gonorrhea is bacterial (2.) single IM injection of penicillin G is treatment of choice for syphilis (3.) CORRECT— CDC-recommended treatment for gonorrhea; instruct client how to prevent transmission of sexually transmitted diseases (4.) can be used for gonorrhea; because is not the CDC recommendation, is not MOST likely treatment

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? 1. Increase the employees' ability to manage personal stress. 2. Increase the employees' level of professional socialization. 3. Decrease the number of accidental injuries among the employees. 4. Provide the employees with an appropriate exercise program.

Strategy: Think about each answer. (1.) many health problems, such as headache and peptic ulcer disease, are associated with stress; could reduce absenteeism related to stress-related health problems; is not the major health issue for this population (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 (4.) heart disease is the second cause of death among the ages of 25 to 44 years; because stress, hyperlipidemia, and obesity are related to heart disease, exercise could significantly reduce death caused by heart disease; priority is decreasing unintentional injuries

The LPN/LVN assists the occupational nurse in constructing a long-term health program for a factory in which the greatest number of employees ranges from 20 to 40 years of age. The primary focus of the health program should include which of the following? 1. Reduce employee turnover. 2. Decrease employee absenteeism. 3. Improve the family relations of the employees. 4. Establish disease prevention for the employees.

Strategy: Think about each answer. (1.) most employees within this age range do not leave jobs for health reasons (2.) increasing health status could decrease the percentage of absenteeism because employees generally miss work because of illness; would be a potential outcome, but is not be the primary focus of a long-term health program (3.) divorce rates are high in this age group, but not significant to health needs of employees within this age range (4.) CORRECT— although there isn't much absenteeism in this age group because of diseases, starting a prevention program at this age will pay off when the employees are older and illness is a reason for absenteeism; prevention should be the primary focus of a long-term health program

A client with an eye injury wears a patch over the left eye. The LPN/LVN identifies that the chief visual disturbance that the client will experience while wearing the patch is which of the following? 1. An inability to focus on very near or faraway objects. 2. Difficulty judging the distance of objects. 3. Impaired accommodation to darkness. 4. Seeing floating spots in the affected eye.

Strategy: Think about each answer. (1.) myopia is the inability to distinctly see objects that are distant to the client; hyperopia is the inability to distinctly see objects that are near to the client; eye patch does not alter these abilities (2.) CORRECT—depth perception depends on binocular vision, meaning two eyes moving simultaneously; with one eye covered, depth perception is lost; in order to make necessary adjustments, the client needs to be aware of needed adjustments (3.) occurs with retinitis pigmentosa; not related to having one eye covered (4.) occurs with detached retina or with aging

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

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 assistant to monitor for which of the following? 1. Allergic reaction. 2. Signs/symptoms of infection. 3. Increased serum glucose level. 4. Petit mal seizures.

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 assists in the discharge teaching of a client diagnosed with hepatitis B. Which of the following precautions should be included when teaching the client how to prevent the transmission of hepatitis B? 1. Burn used paper tissues. 2. Abstain from unprotected sexual intercourse. 3. Use special disinfectant in toilet. 4. Avoid touching family members.

Strategy: Think about the outcome of each answer. (1) hepatitis B transmitted through parenteral drug abuse, sexual contact, and contact with blood and bodily fluids (2) CORRECT—sexual contact is one way to transmit hepatitis B; unless a prospective partner is immune to hepatitis B, by virtue of either having had the disease or having received the vaccination, client should avoid unprotected sexual intercourse with that person (3) transmitted through blood, saliva, semen, and vaginal secretions; drainage or secretions containing blood from body orifices could contaminate commode; no special disinfectant is known to destroy the virus (4) not appropriate unless family member has wound that would risk exposure to blood; generally not transmitted through casual contact

The LPN/LVN makes a home visit to a family that has recently adopted a newborn. The mother is very concerned about the newborn's respiratory rate. Which of the following sustained respiratory rates would cause the LPN/LVN to notify emergency services? 1. 25-40/min. 2. 30-50/min. 3. 60-80/min. 4. 110-120/min.

Strategy: Think about the outcome of each answer. (1) this respiratory rate would not require emergency services (2) normal rate for newborns (3) indicative of physiological distress; if unable to decrease respiratory rate by comforting the infant, rate warrants immediate intervention (4) CORRECT—extreme range; requesting assistance of emergency service is appropriate

A client is admitted to the hospital with a temperature of 101 F (38.3 C) and a WBC count of 3,000/mm3. The LPN/LVN should institute which of the following precautions? 1. Contact precautions. 2. Airborne precautions. 3. Droplet 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 LPN/LVN completes the pre-administration form for a 6-month-old client scheduled to receive the DPT vaccination. Before administering the medication, the LPN/LVN notifies the supervising nurse about which of the following information? 1. The infant has been exposed to lower gastrointestinal (GI) viral infection. 2. The infant has been exposed to three children with a sore throat (streptococcal) infection. 3. The infant has a runny nose and temperature of 100°F (37.8 C) and is restless and crying. 4. The infant is dehydrated, sleepy, and irritable due to teething.

Strategy: Think about the significance of each answer and how it relates to DPT administration. (1) vaccination may be administered if child has been exposed to common elements such as GI viruses (2) vaccination can be administered (3) CORRECT—may administer vaccination if client has mild febrile illnesses; need to check with supervising nurse because client's fever would be considered borderline; otherwise would acceptable to administer the medication (4) symptoms not significant to warrant withholding or questioning vaccine administration

The LPN/LVN completes the admission forms for a 4-year-old girl diagnosed with idiopathic hypopituitarism. It is important that the LPN/LVN include which of the following statements when talking with the family? 1. "You should find furniture that will be appropriate for your child's body proportions." 2. "Your child is likely to display signs of early sexual maturation." 3. "Your child will need medication prescribed for frequent headaches." 4. "You can manage your child's coarse, dry skin by placing oil in her bath.

Strategy: Think about what the answers mean. (1) CORRECT—idiopathic hypopituitarism is diminished or deficient secretions of pituitary hormone; height is below normal due to lack of growth hormone; height may be retarded more than weight (2) sexual development is usually delayed (3) more likely to occur with hyperpituitarism; increased growth hormone results in increased intracranial pressure, resulting in headache (4) indicates decreased thyroid-stimulating hormone; decreased TSH can occur but is not the most common clinical manifestation

The LPN/LVN cares for a client diagnosed with tuberculosis. The LPN/LVN recognizes that which of the following are signs/symptoms of tuberculosis? Select all that apply: 1. Night sweats. 2. Weight gain. 3. Sudden-onset shortness of breath. 4. Progressive fatigue. 5. Acute chest pain. 6. Cough with mucopurulent sputum.

Think about each answer. (1.) CORRECT— tuberculosis is highly communicable; caused by Mycobacterium tuberculosis; transmitted by aerosolization; causes pneumonitis; has low-grade fever (2.) experiences nausea, anorexia, and weight loss (3.) onset insidious; usually has progressive fatigue, weight loss, and low-grade fever (4.) CORRECT— onset insidious; usually has progressive fatigue, weight loss, and low-grade fever (5.) may complain of tightness of the chest and a dull, aching chest pain (6.) CORRECT— bacillus multiplies in bronchi or alveoli, causing pneumonitis; mucous occasionally streaked with blood