Nur 176 final
The nurse is obtaining a health history of a patient diagnosed with diabetes mellitus, hypertension, and high cholesterol. The nurse is teaching the patient about risk factors for stroke. Which statement by the patient requires further teaching?
"I can stop taking my blood pressure medicine as soon as I feel better." **
Which statement about impetigo indicates a need for further teaching by the nurse
"I can't infect others once my sores are closed"
The nurse is educating the patient about the shingles virus. Which statement by the patient indicates the education was effective?
"I could get chickenpox from exposure to shingles since I have never had chickenpox before"
Which statement shows that a client needs more education about the cause of an exacerbation of systemic lupus erythematosus (SLE)
"I don't have to worry if I get strep throat" **
The LPN is teaching a client diagnosed with Rheumatoid arthritis. Which statement indicates the need for further teaching?
"I must avoid all omega 3-fatty acids such as salmon." **
The LPN is providing teaching to a patient diagnosed with Celiac disease. Which statement by the patient indicates an understanding of the disease process?
"I must learn to adjust to a gluten-free diet."
Which statement made by a client with a chlamydial infection indicates understating of the potential complications
"I need to treat this infection so it doesn't spread into my pelvis because I want to have children someday."
The LPN is caring for a patient at a clinic visit who states they have an allergy to bees. Which statement by the patient indicates that further teaching is required
"I should expect to take allergy shots for the rest of my life.?"
The LPN is caring for a patient diagnosed with Type 2 diabetes mellitus who has started taking Glucophage (Metformin). The patient states, "I have been having nausea and diarrhea since I started this medication." How will the LPN best respond to this?
"I will contact your doctor to discuss the possibility of ordering a different medication."
The LPN is teaching a patient newly diagnosed with Type 1 diabetes about how to administer insulin. Which statement by the patient indicates that further teaching is necessary?
"I will inject insulin into intradermal tissue."
The LPN is caring for a patient who has a history of IV drug abuse and prostitution. Which statement by the patient demonstrates a need for teaching?
"I will wear a condom when my genital warts show up."
The LPN is working at a health care clinic giving immunizations. Which is a correct statement by the LPN?
"Immunizations provide acquired immunity."
The nurse is treating a diabetic patient with a new wound. Which statement made by the nurse would indicate understanding of the diabetic wound healing process?
"Keeping your blood sugar levels within normal range will assist with healing."
The LPN is caring for a client with HIV, and is educating them on why multi-drug therapy is needed. Which statement by the patient indicates that this teaching was effective?
"Multi-drug therapy could improve the effectiveness of the treatments"
The nurse is providing care to a patient diagnosed with delirium who is experiencing hallucinations and confusion. Which statement by the staff best indicates an understanding of this condition?
"Treatment is possible once the cause of the delirium is identified."
The nurse is review the client's medication list and notices that the patient takes phenytoin(Dilantin). Which question is the nurse most likely to ask?
"When was the last time you had a seizure?"
The LPN is caring for a client with a diagnosis of venous thrombosis in the lower left leg who is receiving heparin sodium by continuous intravenous (IV) infusion. The nurse should monitor the client for which manifestation indicating an adverse effect of this therapy?
Dark urine
The nurse is providing care for a patient recently diagnosed with genital herpes. Which statements should the nurse provide to this client? Select all that apply
"You will need to keep your immune system healthy to reduce the risk of exacerbation." ** "Oral sex with your partner can infect them with this condition also." ** "This virus can lay dormant in your body for years." ** "It is important to practice safe sex at all times to reduce the risk of transmission." **
Which conditions increase the risk of contracting shingles? Select all that apply.
Aging over 65 years old ** Having a compromised immune system ** Having excessive stress
The LPN is caring for a patient with anemia. Which assessment and interventions should be taught related to this condition? Select all that apply.
Alternate periods of rest and activity Assess for poor thermal regulation and poor pallor Monitor urine and stool for signs of bleeding
An IV has been ordered of Lactated Ringers 1000ml stat over a 4 hour period, and, is initiated at 1400 hours. How much is left in the IV bag at 1700 hours
250ml
A patient has a left upper arm fistula for dialysis. The nurse will demonstrate which precautions for this client? Select all that apply
Ensure staff is aware of the need to use only the right arm for blood pressures Avoid blood draws or needle sticks to the left arm ** Check the site after dialysis for signs of bleeding **
The LPN is caring for a patient with DIC (Disseminated Intravascular Coagulation). Which signs and symptoms could be observed related to this condition? (Select all that apply)
Excessive bruising and gum bleeding Petechiae appearing on the chest and other areas Abdominal tenderness and pain **
During a physical assessment of a patient, the LPN would be concerned by which findings? Select all that apply
A large discolored red/black mole located on the back ** A raised black nevi with irregular edges ** A nevi with hair growing in it that bleeds occasionally ** A new sore that will not heal and bleeds easily
A client has been admitted to the clinic with primary syphilis. Which sign or symptom should the nurse expect to see with this diagnosis?
A painless genital ulcer that appeared about 3 weeks after unprotected sex
The LPN is caring for a patient with a butterfly rash on the face. The client is complaining of numbness, tingling in the legs and arms, and being sore all over. Which laboratory tests does the LPN anticipate being ordered for this patient?
ANA (Anti-nuclear antibody) and CRP (C-reactive protein)
The LPN is caring for a patient with a viral infection. Which medication would the LPN expect to be ordered for the treatment of this condition?
Acyclovir (Zovirax)
A patient with Type 2 diabetes mellitus has the following insulin order: Lantus 30 units sq daily and regular Aspart insulin 8 units every morning just before meals. The patient's blood sugar reading is 167. How will the LPN administer the insulin?
Administer both insulins separately in two different syringes
The LPN is caring for a patient having a sickle cell crisis. Which interventions should be initiated? Select all that apply
Administer oxygen ** Provide pain management ** Initiate hydration methods **
A patient with Type II diabetes has the following insulin orders: Lantus 34 units, and Regular insulin 10 units every morning. How will the LPN administer the insulin?
Administer the insulin separately in two different syringes
The nurse is caring for a client with rheumatoid arthritis. When is the best time to schedule the client for ambulation?
After the client has a bath
The LPN is assisting with the development of a plan of care for a client diagnosed with ringworm. Which medication should the nurse anticipate discussing with the client
Antifungal
The LPN is caring for a patient who called the physician's office and stated that she was stung by a bee. She is afraid of severe reaction because her neighbor was hospitalization last week from a bee sting What action will the nurse take next?
Ask the patient is she was previously stung by a bee sting in the past and what her reaction was
The LPN is caring for a patient who has a latex allergy and is scheduled for surgery later today. What should the LPN do next?
Ask the patient to describe what happens when they are exposed to latex
The LPN is caring for a patient with a history of congestive heart failure (CHF) that is presently experiencing dyspnea. The patient has an IV running at 150ml/hr. What is the nurse's next action?
Assess respiratory status and vital signs.
The nurse is assisting a patient who had a stroke yesterday. When re-positioned in bed, the patient becomes confused and agitated. What is the nurse's next action?
Assess the patient's level of consciousness
The LPN is caring for a patient with systemic lupus erythematosus. What teaching should be included in the plan of care? Select all that apply.
Avoid direct sunlight and use protective clothing Balance rest with activity Eating a balanced diet, low in sodium
The nurse is educating the patient on skin cancer safety practices. Which statements will the nurse include during this education? Select all that apply.
Avoid long periods in the sun without proper skin protection ** Perform skin self-examinations after showering in a head-toe fashion ** Note any changes in color or size of moles
Which neurological condition requires isolation precautions to prevent infecting other clients
Bacterial meningitis
A client is receiving clopidogrel (Plavix). Which symptoms should the nurse monitor for while the patient is on this medication? (Select all that apply)
Blood in the stool Ecchymosis Hematuria Patechiae
The LPN is caring for a patient with impaired kidney. The patient is receiving furosemide(Lasix) 40mg IV daily. Which information requires action by the nurse? Select all that apply
Blood pressure reading of 88/40 ** Lab results of creatinine of 3.6 ** Serum potassium level of 2.9 mEq/L
A client is diagnosed with scabies. Upon assessment, the LPN anticipates which findings may be noted? Select all that apply
Brown crusty lines around wrist or skin folds ** Red bumps and severe itching (pruritus)
A client was admitted with meningitis. Which finding would support the diagnosis? (Select all that apply)
Brudzinski sign ** Kernig sign **
The nurse is caring for a patient diagnosed with lupus. Which signs or symptoms would the LPN expect could be present related to this condition? Select all that apply
Butterfly rash on the face Low endurance with activity Joint pain ** Sensitivity to sunlight
The nurse is assessing a client with pernicious anemia. Which data collected would support this diagnosis (Select all that apply)
Cracked corners of the mouth ** Smooth, bright red tongue ** Sensitivity to cold ** Dyspnea on exertion
The LPN is caring for a patient with opportunistic infections of pneumocystis jiroveci pneumonia and Kaposi sarcoma. Which tests would the nurse expect to be ordered for this patient?
CD4 cell count
The nurse is concerned about the patient's renal status. Which labs would they recommend as primary indicators of a renal condition? Select all that apply
Creatinine ** Specific gravity ** BUN **
The nurse is caring for a patient with diabetes mellitus who is concerned about developing long-term complications. Which interventions would the nurse educate the patient on as best practices? Select all that apply.
Ensure daily foot exams are done by the patient ** Request annual renal function tests by your doctor ** Maintain ideal LDL under 70mg/dL for optimal health
The telemetry monitor technician notifies the nurse that a client has sinus bradycardia with a heart rate of 42 beats/min. What should the nurse do first?
Check the client's level of consciousness, obtain vital signs, and ask the client about symptoms
The LPN is assessing a client who began peritoneal dialysis a week ago. The nurse should suspect the onset of peritonitis if which finding is noted on assessment?
Cloudy dialysate output
Which intervention does the nurse determine has the most impact in delaying the development of acquired immunodeficiency syndrome (AIDS) once a client has been infected with the human immunodeficiency virus (HIV)
Compliance with the complete therapeutic regimen
The LPN is caring for a client diagnosed with BPH (benign prostate hypertrophy) with a 5.5 PSA (prostate-specific antigen) lab level. What information would the LPN need to collect to confirm the symptomatic conditions of this diagnosis?
Difficulty with urinary retention
Which assessment finding is most indicative of late elevated intracranial pressure (ICP)?
Dilated and fixed pupils bilaterally
The nurse is caring for a patient who exhibits sudden convulsions and stiffened muscles. Which action would be the highest priority for client safety?
Do not leave the patient unattended during the potential seizure
The LPN is reviewing discharge instructions with a patient who now has a colostomy. Which instruction should be included in the discharge plans?
Empty the pouch when it is one-third full
The LPN is caring for a woman who is 6 months pregnant and HIV positive. The mother is concerned her baby will contract HIV. What patient education will the LPN provide to this mother concerning the reduction of risk for transmitting HIV to her child?
Feed the baby formula instead of breast milk
The nurse is educating staff members on isolation precautions for scabies. Which PPE will be used when caring for a patient with this condition?
Gloves and gown
The nurse is caring for a patient suspected of developing early-stage dementia. The nurse will assess for which signs or symptoms related to this stage? Select all that apply.
Gradual onset of short-term memory loss ** Difficulty focusing attention
The LPN is caring for a client with HIV and is educating him on proper nutrition. Which diet below indicates an understanding of the best diet for an HIV patient?
High calorie, high protein, high potassium diet.
The LPN is caring for a patient who has tested HIV positive, complains of having difficulty swallowing the last few weeks, and notes white and purple patches in the mouth. Which intervention will the nurse plan for the patient related to this information?
Increase fluids with the use of a straw
The LPN is caring for a patient just following an abdominal CT scan with contrast. Which intervention would be best to implement post procedure?
Increase oral fluids to prevent renal complications
A client is diagnosed with acquired immunodeficiency syndrome (AIDS) is hospitalized. The nurse develops a plan of care and determines that which intervention is the priority?
Instituting measures to prevent infection in the client
The nurse is discharging a patient who has signs and symptoms of left-sided paralysis and has had frequent falls. What teaching will the nurse implement to best promote safety and prevent further falling?
Instruct the patient on safety devices and proper equipment
The LPN will expect to see which signs or symptoms in the patient who is exhibiting right-side heart failure
Jugular Vein Distention
The LPN is caring for a patient diagnosed with herpes zoster (shingles virus). Which instructions should be included in the discharge teaching? Select all that apply.
Keep active blisters covered ** Acyclovir medication use is most beneficial in the first 72 hours Take pain medication to reduce discomfort from blisters along the nerve tract. ** Limit visitors to the home while lesions are still present.
After a recent myocardial infarction (MI) and heart catheterization, cardiac rehabilitation is ordered. The LPN should expect what interventions with this treatment? Select all that apply.
Low sodium (Nat) diet Exercise-based rehab program Lifestyle modification teaching
The LPN is caring for a patient admitted to the emergency department due to experiencing an anaphylactic reaction after ingesting peanuts. Which action would be most important for the LPN to take?
Maintain a patient airway
The LPN is caring for a patient receiving penicillin started 15 minutes ago per IV. The LP notices that the patient's vitals are R: 32, BP: 80/40, P: 124 presently, with severe wheezing and dyspnea. Which interventions will the LPN expect to be implemented immediately? Select all that apply.
Maintain patent airway ** Administer IM Epinephrine as ordered Administer oxygen per order
Which nursing intervention is priority in caring for a client diagnosed with Alzheimer disease (AD)
Make sure the environment is safe to prevent injury
The patient presents to the emergency department with dyspnea, BP of 200/130, blurred vision, and severe headache. The patient has a history of hypertension (HTN) and high cholesterol. The LPN suspects they are experiencing which condition?
Malignant hypertension
The nurse is caring for a patient with a head injury who is receiving a loop diuretic intravenously. Which action is the most important related to this treatment
Monitoring potassium levels after treatment
The nurse is caring for a patient who fell down the stairs. The vital signs are temp 98.3F, pulse 115, BP 90/56, RR14. What immediate action should the nurse take before transport of this patient?
Perform a neurological assessment on the patient
The LP is caring for a patient with left-sided -heart failure. Which signs and symptoms below indicate left-sided heart failure? Select all that apply.
Pink frothy sputum noted when coughing ** Nocturnal dyspnea when laying flat ** Pulmonary crackles on assessment
What is the priority nursing action for a post-operative client who has been admitted with Clostridium Difficile (C-Diff)
Place the client in a private room and wear gloves and gown during nursing care
Which intervention would be most appropriate for a patient diagnosed with hemophilia who is having acute knee pain and edema?
Place the patient on bed rest, and apply an ice pack carefully
The nurse is caring for a 30-year-old patient diagnosed with Type 2 diabetes and a blood glucose level of 280 prior to breakfast. Which symptom would best indicate a hyperglycemic condition?
Polyuria and polydipsia
What is the primary purpose of continuous bladder irrigation after a TURP procedure?
Prevent blood clots from forming
Which interventions will the nurse carry out for the patient requiring care for cellulitis? Select all that apply.
Provide antibiotic treatment ** Offer analgesics if ordered ** Protect from secondary infections with aseptic care
The LPN is caring for a patient who is at risk for skin cancer. Which assessment data is most significant to report?
Purplish-red raised moles on the skin
The nurse is working on an acute care unit and is admitting a patient with a myoclonic seizure disorder. Which intervention will require further teaching?
Remove padded side rails from the bed
The nurse observes a patient with dementia yelling at another patient. They are highly agitated and difficult to redirect. What will the nurse do initially?
Remove the patient from the location with overstimulating conditions.
The LPN is caring for a patient who states "It feels like I am peeing razor blades." Which assessment data and interventions should the LPN include in the plan of care? Select all that apply.
Request an order for a specimen culture for suspected gonorrhea Ask if the client has had unprotected sex recently ** Assess the patient for any purulent drainage from the urethra or rectum
A patient presents to the emergency department with facial drooping, dysarthria, right arm weakness, and a suspected CVA (cerebral vascular accident). The vital signs are BP 96/52mmHG, HR 116, RR24, and 02 sat at 90%. Which interventions should the nurse anticipate requesting for this patient? Select all that apply.
Requesting a CT scan or MRI to rule out hemorrhagic stroke Completing a neurological assessment using the stroke scale Assessing for any signs or symptoms of bleeding
The nurse is caring for a client reporting weight gain, nausea, and decreased urine output. Which condition should the nurse suspect?
Right-sided heart failure
The nurse reviews discharge instructions with a patient taking Heparin. Which side effects should the nurse instruct the patient to report immediately to the health care provider related to this drug? Select all that apply
Sudden severe nosebleed ** Excessive rectal bleeding ** Increased bruising
The LPN is aware that clients exhibiting lethargy, general weakness, and shortness of breath on exertion, are potential signs of which condition?
Severe anemia
The LPN is providing care to a patient diagnosed with renal failure who has a potassium level of 7.5 mEq/L. Which medication will the LPN anticipate being ordered to address this situation?
Sodium polystyrene sulfonate (Kayexalate)
The patient is experiencing an exacerbation of herpes simplex 2 (genital herpes). Which teaching will the nurse prioritize for the patient?
Starting to take the antiviral prescribed in the first 72 hours for best results
The nurse is assisting a client who was just diagnosed with celiac disease complete their menu. Which lunch option would be the best choice for the patient
Stir-fry vegetables with rice and orange slices
The LPN notes that a client is taking metoprolol. The nurse should perform which assessment to determine medication effectiveness
Take the client's blood pressure
The nurse is educating the patient with diagnosed rheumatoid arthritis (RA). Which statement would the nurse include in the teaching?
This condition can affect synovial membrane and many of the body organs as it progresses
The LPN is caring for a patient with recurrent herpes simplex infection. Which information should be included in the patient education plan
This condition can be transmitted with unprotected sex.
The nurse notes a melanoma during a client skin assessment on admission. This type of neoplasm is best described by which statement?
This often indicates malignant skin cancer cells
Which treatment will the nurse anticipate for a patient with open sores and fissures noted on the toes who is complaining of severe pruritus?
Treatment with an antifungal medication
The LPN would report which lab results to the RN as a concern? (Select all that apply).
Urine specific gravity of 2.135 ** Creatinine level of 2.1 ** Blood Urea Nitrogen (BUN) of 27.0 ** INR of 4.5 **
The patient diagnosed with lupus is experiencing pain in their joints, as well as a general stiffness upon awakening. Which intervention would be best for pain relief related to this condition?
Use of anti-inflammatory medication and frequent rest periods
The nurse is providing care to a patient who experienced a stroke yesterday. What should not be included in the plan of care?
Use of straws with fluids
The nurse is educating the parents of a 22-month- old toddler assessed with head lice (pediculosis). Which action will the nurse teach to the parents
Using Vaseline product to coat the hair
The LPN is caring for a patient diagnosed with HIV. Which precautions should the LPN take while caring for this individual? Select all that apply.
Wash hands before and after contact with the patient Use needles with a safety cap to reduce the risk of needle sticks Wear gloves when changing bed sheets or patient undergarments
The nurse is treating a patient with contact dermatitis. Which assessment information is the most important to obtain?
What new products or items the patient has been exposed to