k np 2018 - 7
The LPN/LVN in the outpatient clinic observes a client diagnosed with trigeminal neuralgia. The LPN/LVN should intervene if the client makes which statement? 1. "I drink coffee with breakfast and after dinner." 2. "I like to eat creamed soups at room temperature." 3. "I can't wait to eat my spouse's homemade applesauce." 4. "I drink tomato juice during my afternoon break."
Strategy: "Should intervene" indicates something is wrong. (1.) CORRECT—hot foods can trigger a pain episode (2.) instruct client to avoid foods that are too hot or too cold (3.) room-temperature foods and fluids are best; teach client to chew on the unaffected side (4.) soft foods are better tolerated
The LPN/LVN contributes to the dietary instruction of a client with full thickness burns of the legs. The LPN/LVN determines teaching is successful if the client selects which of the following menus? 1. Meat and orange juice. 2. Whole grain bread and an apple. 3. Green vegetables and milk. 4. Peanut butter and a banana.
Strategy: "Teaching is successful" indicates correct information. (1) CORRECT—includes both meat, which is an excellent source of protein, and orange juice, which is an excellent source of vitamin C; protein is necessary to offset the catabolism caused by the burn and to promote healing; vitamin C also promotes wound healing (2) deficient in complete protein and vitamin C (3) not the highest in protein and vitamin C (4) contains protein but lacks vitamin C
The LPN/LVN cares for clients at a nursing home. The LPN/LVN notes that many of the clients are awake frequently during the night and sleep during the day. The LPN/LVN should take which of the following actions? 1. Obtain sleeping aids, such as sedatives. 2. Make each client's unit resemble home. 3. Plan activities for clients during the night. 4. Create a quiet, sleep-inducing environment.
Strategy: Determine the outcome of each answer. Is it desired? (1.) more effective to adjust the clients' activities (2.) external environment is not the primary problem; insomnia involves physiological changes in the older adult (3.) CORRECT— 50% of older adults report having trouble sleeping through the night; circadian rhythm changes in the older adult result in a change in the sleep/wake cycle; appropriate to correlate agency activities according to the needs of the population (4.) environmental adjustment needs to be conducted when scheduling activities
The LPN/LVN cares for clients in the pediatric clinic. The LPN/LVN understands that according to Erikson's stages of psychosocial development, trust and significant early attachments develop during which of the following years of life? 1. Birth to 18 months. 2. 8 months to 3 years. 3. 3 to 6 years. 4. 6 to 12 years.
Strategy: Think about each answer. (1) CORRECT—from birth to 18 months, the baby learns what is predictable and dependable about the environment and the primary caretaker; these are the basic elements of trust; if all goes well at this time, the attachment between parents and child is strong and the child can move on to exploring and manipulating the environment (2) toddler works to achieve autonomy; to learn self-control and how to manipulate the environment (3) preschooler works on initiative; learns assertiveness and purpose to influence environment; begins to evaluate own behavior (4) school age child works to master industry; develops a sense of completeness
An infant is able to assume a sitting position, plays "peek-a-boo," and is starting to say "mama" and "dada." The LPN/LVN identifies these behaviors are characteristic of which age? 1. 5 months. 2. 6 months. 3. 9 months. 4. 12 months.
Strategy: Think about each answer. (1) at 5 months, infant squeals and makes cooing sounds (2) takes pleasure in hearing own sounds, begins to imitate sounds (3) CORRECT—at 9 months, the infant is able to pull himself up and assume a sitting position as well as say words such as "dada" and "mama" (4) comprehends the meanings of several words; recognizes objects by name; says three to five words besides "dada" and "mama"
The LPN/LVN cares for a client diagnosed with Ménière's disease. The client is most likely to exhibit which symptoms? 1. Hearing loss, irritability, weight loss. 2. Vertigo, hearing loss, tinnitus. 3. Ringing in the ears, ear pain, mucoid drainage. 4. Nausea, vomiting, hypotension.
Strategy: Think about each answer. (1.) weight loss and irritability may occur because of the enormous discomfort associated with the disease; hearing loss is not common (2.) CORRECT—Ménière's disease is an inner ear disorder involving fluid imbalance, characterized by this triad of symptoms (3.) consistent with otitis media (4.) nausea and vomiting may occur with Ménière's, but hypotension does not
A young client is brought to the college infirmary by a friend. The client is agitated and is screaming, "I can't stop seeing things. Help me, I'm going crazy." The friend reports to the LPN/LVN that the client took some LSD earlier in the day. Which action by the LPN/LVN is best? 1. Call 911. 4. Stay with the client and place the client in a quiet room.
(1) CORRECT LSD is a hallucinogen that causes marked confusion, hyperactivity, incoherence, hallucinations, delirium, mania, and self injury; care includes maintain airway, control seizures, assess LOC and vital signs, check for trauma, and protect from self-injury; psychosis indicates overdose (4) do not leave client alone
The LPN/LVN admits an infant born to a diabetic client one hour ago. The infant weighs 8 lb, 8 oz, apical pulse is 128 bpm, respiratory rate is 32/min with periodic apneic episodes, and the blood glucose is 35 mg/dL. It is most important for the LPN/LVN to take which action? 1. Offer the infant formula or breast milk. 2. Continue to monitor the infant for potential problems.
(1) CORRECT glucose levels less than 40 mg/dL considered hypoglycemia; due to abrupt loss of maternal glucose but not a corresponding drop in fetal insulin production; feed infant early to prevent hypoglycemia (2) neonate is hypoglycemic, no validation required; signs include jittery movements, twitching, lethargy, apathy, convulsions, sweating
The LPN/LVN prepares to administer the initial dose of furosemide to a client. It is most important for the LPN/LVN to review the client's record for which client data? 1. Allergy to sulfa medications. 3. Admission weight and current weight.
(1) CORRECT— furosemide (Lasix) is a sulfa-based drug; sulfa is a common allergen; Lasix is a loop diuretic; side effects include hypotension, hypokalemia 3) since is diuretic, can significantly alter weight; not necessary before administering drug
The LPN/LVN observes a 9-month-old in the pediatric clinic. The LPN/LVN expects which of the following reflexes to be present? 1. Babinski reflex. 2. Moro reflex. 3. Tonic neck reflex. 4. Palmar grasp reflex.
(1) CORRECT—Babinski reflex disappears at 12 months; stroking the outer sole of the foot upward from the heel across the ball of the foot causes the big toe to dorsiflex and the toes to hyperextend (2) disappears by 4 months; sudden loud noise causes abduction of the arms with flexion of elbows (3) disappears at 3 to 4 months; infant's head is turned to one side, arm and leg extend on that side, and opposite arm and leg flex (4) palmar grasp lessens after 3 months; touching palms of hands near base of digits causes flexion of the hands
Which of the following guidelines is appropriate for the LPN/LVN to give a mother concerning the development of her 7-year-old daughter? 1. The child's periods of shyness should be tolerated. 4. Severe punishment may be necessary for acts of independence.
(1) CORRECT—a 7-year-old girl may become shy at times because she experiences a conflict regarding her independence from her mother; to allow the daughter to become independent, the mother should allow these episodes of shyness (4) children are working toward independence
During an initial home visit to a client diagnosed with a myocardial infarction (MI), the client's spouse tells the LPN/LVN, "I am having difficulty coping with my spouse's 'obsessive-compulsive' tendencies." Which statement, if made by the client to the LPN/LVN, is consistent with obsessive-compulsive disorder? 1. "I have difficulty making decisions and adjusting to change." 4. "I spend money excessively, which upsets my spouse."
(1) CORRECT—clients with obsessive-compulsive disorder have an extreme need to control and predict outcomes; making decisions and adjusting to changes are anxiety-producing for these clients (4) characteristic of bipolar disorder
The LPN/LVN instructs a group of clients about dietary habits to reduce the risk of cancer. Which of the following statements, if made by a client to the LPN/LVN, indicates that further teaching is necessary? 1. "Eating polyunsaturated fats will decrease my chances of developing cancer." 2. "I should increase my intake of foods high in fiber." 3. "I should eat apricots, carrots, leafy vegetables, and citrus fruits
(1) CORRECT—diet high in fat is a risk factor for the development of colon cancer; does not matter whether fat is saturated or polyunsaturated; limit total fat intake to less than 30% of daily intake (2) helps protect against colon cancer; also increase intake of foods from cabbage family (broccoli, cauliflower, Brussels sprouts, and cabbage) (3) provides vitamin A and vitamin C, which act as antioxidants; reduces risk of cancers of the lung, esophagus, larynx, and bladder
The LPN/LVN completes the admission forms for a preschool-aged child diagnosed with idiopathic hypopituitarism. It is important that the LPN/LVN include which statement when talking with the family? 1. "You should find furniture that will be appropriate for your child's body proportions." 4. "You can manage your child's coarse, dry skin by placing oil in her bath."
(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 (4) indicates decreased thyroid-stimulating hormone; decreased TSH can occur but is not the most common clinical manifestation
A middle-aged client is admitted to the hospital for hematuria. The client has no previous history of illness, is married, and has three children in high school. Which task of middle adulthood is MOST likely to be disturbed by a physical disability? 1. Assisting the children to grow to into adulthood. 4. Developing adult leisure-time activities.
(1) CORRECT—middle adulthood is the time of guiding the next generation; this occurs not only in family life but also in one's professional career; if this developmental task is not achieved, client becomes self-absorbed (4)middle-aged adults find that they have more financial resources and more leisure time; LPN/LVN should instruct client about the importance of engaging in daily leisure activity
The LPN/LVN assists with the discharge teaching for a client diagnosed with chronic obstructive pulmonary disease (COPD). When the client's wife asks why the concentration of the supplemental oxygen cannot be increased when the client is having difficulty breathing, the MOST appropriate response by the LPN/LVN should be based on which of the following? 1. High-flow oxygen interferes with breathing. 2. Low-flow oxygen will not improve breathing. 3. High-flow oxygen will stimulate breathing. 4. Low-flow oxygen is more comfortable.
(1) CORRECT—progressive loss of recoil of lung tissue results in air trapped in the lung tissue as well as an arterial hypercapnia; hypoxemia stimulates the client to breathe; sudden increase of oxygen (O 2) in the blood can decrease this stimulus, which would suppress the respiratory drive; recommended that clients receive constant low oxygen (O 2) of 1-2 L/min (2) low-flow oxygen (O 2) will not interfere with client's stimulation to breathe (3) decreases stimulation to breathe (4) dyspnea would decrease, resulting in greater comfort, but this is not primary reason for administering low-flow oxygen (O 2)
A depressed parent of two school-age children tells the LPN/LVN that the spouse has recently become unemployed. The LPN/LVN understands which fact is true? 1. The spouse's unemployment is a significant potential stressor. 2. The spouses's unemployment is irrelevant to the client's recurrent depression
(1) CORRECT—the loss of financial resources when a client is currently experiencing clinical depression is likely to increase the depth or intensity of the depression and reduce the effectiveness of prescribed interventions (2) any major event can affect depression
The LPN/LVN cares for a client after a traditional cholecystectomy. The LPN/LVN should notify the supervising nurse if which of the following is observed? 1. 800 cc bloody drainage during the first day postop. 2. The client frequently complains of abdominal pain during the first 24 hours.
(1) CORRECT—this amount of drainage after a cholecystectomy would indicate hemorrhage; 50 cc is an appropriate amount of drainage (2) incisional pain common; treated with meperidine (Demerol) using a client-controlled analgesia pump; plan coughing and deep breathing when pain medication is most effective
The nurse in a 50-bed nursing facility discovers a fire in the soiled utility room. In which order will the nurse perform the actions? Move clients away from the fire Locate all of the residents Pull the fire alarm after removing clients Close all of the fireproof door
(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 nurse prepares a client for surgery. Place the following preoperative activities in the correct sequence from FIRST action to LAST. All options must be used. Obtain and record the vital signs Instruct the client to remain in bed Verify that operative permit is signed Ask the client to empty the bladder Administer preoperative medication
(1) Verify that operative permit is signed: perform first before continuing preparation; confirm that lab results are posted (2) Obtain and record the vital signs: provides baseline for anesthesiologist (3) Ask the client to empty the bladder: do not allow client to ambulate after receiving preoperative medication (4) Instruct the client to remain in bed: safety measure; raise side rails and put bed in low position (5) Administer preoperative medication: provide all nursing care prior to administering preoperative medication
The day after a bone-marrow aspiration to determine the reason for an excessive WBC level, an LPN/LVN notices the client is restless and appears very anxious. Which nursing action should the LPN/LVN perform next? 1. Offer to provide reading materials. 2. Report observations to supervising nurse. 3. Allow the client to express feelings about the bone-marrow aspiration.
(1) activity does not match needs; would require sitting still as well as some measure of close concentration; should assess how client usually relieves anxiety (2) need further assessment before making referral (3) CORRECT—should discuss feelings about the test; on the basis of the client's response, can follow up with more focused question
The LPN/LVN monitors a client receiving a blood transfusion. The LPN/LVN should intervene if which is observed? 1. The blood is infused in 3 hours 4. The blood is infused at 10 mL/min for the first 15 min.
(1) blood should be infused within 4 hours of refrigeration 4) CORRECT—blood should be run slowly at first (no faster than 5 mL/min for the first 15 min) with nurse in attendance; if no reaction, regulate blood to the prescribed rate
The LPN/LVN assists the nurse in preparing a client for a colostomy construction. Which statement, if made by the client to the LPN/LVN, indicates further teaching is necessary? 1. "I am pleased I will not have to wear a colostomy bag all of the time." 3. "I hate that they are going to remove my rectum."
(1) coordinating food ingestion with irrigation can aid in regulating the bowel pattern so that a gauze dressing may be worn over the opening (3) CORRECT—rectum is not commonly removed when a colostomy is constructed; is often removed when cancer is located in that area or tissue is greatly impaired and damaged
After a gastrectomy for stomach cancer, a nursing assistive person tells the LPN/LVN the nasogastric tube is "plugged up" and the client reports severe nausea. It is most important for the LPN/LVN to take which action? 1. Irrigate the nasogastric tube immediately. 2. Notify the supervising nurse.
(1) do not irrigate the tube unless there is an order (2) CORRECT— because irrigating the tube can put pressure on the suture line, never irrigate the tube unless it is specifically ordered; the supervisor will notify the assigned health care provider
The LPN/LVN cares for substance-abusing clients. The LPN/LVN understands the nursing care of substance-abusing clients is based on which principle? 1. The clients have difficulty making decisions. 4.. The clients have a limited ability to tolerate anxiety.
(1) limited ability to tolerate anxiety may contribute to some difficulty with decision-making (4) CORRECT—clients who abuse drugs have a low frustration tolerance and use drugs to escape difficult feelings
A client with type 1 diabetes mellitus is placed on a diet of 1,800 calories/day. The LPN/LVN instructs the client which food is a suitable exchange for one pat of butter? 1. 1/2 cup of milk. 2. 2 cups of yogurt. 3. 1/2 cup of cabbage. 4. 1 tbsp of mayonnaise.
(1) milk is categorized as a protein or a milk exchange (2) yogurt is categorized as protein and carbohydrate or a milk exchange (3) cabbage is a vegetable and can be exchanged for other vegetables (4) CORRECT—1 tbsp of mayonnaise is considered an exchange for a pat of butter; one fat exchange equals 5 grams of fat and 45 calories
The LPN/LVN cares for a newborn delivered by a client addicted to narcotics. During which time is the LPN/LVN most likely to observe symptoms of narcotic withdrawal? 1. Immediately at birth. 2. Within 12 hours after birth. 3. Within 24 to 72 hours after birth. 4. After 2 weeks.
(1) too soon, client may have taken drugs immediately prior to admission to the hospital (2) withdrawal seen 24 to 72 hours after birth (3) CORRECT infant will be jittery and hyperactive, high-pitched cry; diaphoresis, tachypnea (4) if client taking methadone, infant demonstrates signs of withdrawal about 7 days after birth
A liver scan is ordered for a client before surgery. The LPN/LVN understands that which of the following BEST describes the procedure? 1. The client will be strapped to a table and irradiated by a cobalt scanner. 3. The client will be asked to lie still while a scanning probe is passed back and forth over the body.
(1)client will receive an IV injection of a radioactive colloid, which is taken up by the liver and spleen; liver and spleen are scanned (3) CORRECT—client will be placed in many different positions but must lie still during scan; no follow-up care is necessary
A housekeeper accidentally bumps into a newborn's bassinet. The newborn jumps and pulls his extremities into his trunk. The LPN/LVN recognizes that the newborn is demonstrating which of the following reflexes? 1. Tonic neck. 2. Moro's. 3. Babinski's. 4. Rooting.
(1)fencing position; lying on back with head turned to one side, arm and leg on that side of body will be in extension while extremities on opposite side will be flexed; disappears at 3 to 4 months of age (2) CORRECT startle reflex; disappears at 3 to 4 months of age (3)stroking the sole of the foot from heel upward across ball of foot will cause all toes to fan; reverts to usual adult response by 12 months of age (4)turns toward any object touching/stroking the cheek/mouth
The LPN/LVN identifies that which of the following volumes is a typical daily urinary output in the normal adult? 1. 500 mL. 2. 1,500 mL.
(1)oliguria is less than 400 mL/24 hours; caused by dehydration, renal failure, increased ADH secretion (2) CORRECT—typical daily urine output for an adult is 1,500 mL
The LPN/LVN cares for clients in the long-term care facility. The LPN/LVN identifies which clients are likely to develop a potassium imbalance? Select all that apply: 1. A client diagnosed with chronic kidney disease. 2. A client diagnosed with osteoarthritis. 3. A client experiencing vomiting and diarrhea. 4. A client receiving furosemide. 5. A client recovering from a stroke. 6. A client diagnosed with Parkinson's.
(1.) CORRECT— Chronic kidney disease causes hyperkalemia; symptoms include dysrhythmias, muscle weakness, paralysis (2.) osteoarthritis is progressive cartilage deterioration in the synovial joints and vertebrae; does not affect potassium balance (3.) CORRECT— causes hypokalemia; indications include anorexia, nausea, vomiting, muscle weakness, paraesthesias (4.) CORRECT— causes the excretion of sodium, potassium, and water that causes hypokalemia (5.) does not cause a potassium imbalance (6.) caused by a deficiency of dopamine; does not cause a potassium imbalance
The LPN/LVN helps the nurse practitioner instruct a group of expectant mothers about how to recognize the onset of labor. Which of the following statements, if made by the client to the LPN/LVN, indicates further teaching is necessary? 1. "My baby will move more when I go into labor." 3. "I may have blood-tinged vaginal discharge."
(1.) CORRECT— fetal movement remains unchanged during true labor (3.) bloody show; one of the signs preceding labor; other signs include lightening, urinary frequency, backache, surge of energy; stronger Braxton Hicks contractions
Which clinical manifestation is the LPN/LVN most likely to see when caring for a client with a history of multiple sclerosis? 1. Urinary retention. 2. Decrease in level of consciousness.
(1.) CORRECT—because of the progressive demyelination of the spinal cord, gradual weakness leading to paralysis is expected; altered innervation of the bladder and urinary tract is expected, leading to urinary retention (2.) decreased ability to problem-solve can occur; but significant cognitive changes are rare
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. 4. Contact precautions.
(1.) barrier precautions used with all clients to reduce the transmission of pathogen (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 in the outpatient clinic cares for a client diagnosed with Cushing's disease. It is MOST important for the LPN/LVN to instruct the client about which of the following? 1. Monitor weight daily. 2. Avoid individuals with infections.
(1.) because of the reduced basal metabolic rate and fluid retention, client is likely to gain weight; although can have long-term health risks does not place client at significant risks (2.) CORRECT— have increased risk for becoming infected and reduced ability to meet the challenges; this is the most important client teaching parameter
The LPN/LVN in the long-term care facility notes that an elderly client consistently has difficulty sleeping at night. The LPN/LVN should take which of the following actions? Select all that apply: 1. Offer the client hot tea at bedtime. 2. Encourage the client to take a 1-hour nap in the late morning. 3. Give the client a warm bath at bedtime. 4. Decrease fluids 2 hours before bedtime. 5. Offer the client the prescribed analgesic 30 minutes before bedtime. 6. Get the client up if the client is unable to fall asleep within 30 minutes.
(1.) decrease intake of caffeine during the late afternoon and evening (2.) discourage naps during the day; if napping is part of the client's routine, limit nap to 20 minutes (3.) CORRECT — will help promote sleep (4.) CORRECT — do not promote diuresis at bedtime (5.) CORRECT— will decrease aches and pains (6.) CORRECT — perform preferred activity (reading, watching TV, listening to music) until sleepy, then go back to bed
A young mother delivers a healthy 7-lb, 12-oz boy. While the LPN/LVN assists with perineal care, the client expresses concern about the two "soft spots" found on her baby's head. The LPN/LVN's response is based on which of the following? 1. Both of the baby's fontanels should close within the first month. 2. Both of the baby's fontanels should close within 6 months. 3. The baby's posterior fontanel should close after 1 year. 4. The baby's anterior fontanel should close after about a year and a half.
(1.) fontanels are membrane-filled spaces where sutures intersect (2.) incorrect information (3.) triangular in shape; junction of the sutures of the two parietal bones and the one occipital bone; closes 6 - 8 weeks after birth (4.) CORRECT— diamond-shaped; 3 × 2 cm; junction of sagittal, coronal, and frontal sutures; closes by 18 months
The LPN/LVN cares for a client diagnosed with cholecystitis. The client says to the nurse, "I don't understand why my right shoulder hurts when the gallbladder is not by my shoulder!" Which of the following responses by the nurse is BEST? 2. "There is an invisible connection between the gallbladder and the right shoulder." 4.Your shoulder became tense because you were guarding against the gallbladder pain."
(1.) gallstones do not become emboli (2.) CORRECT— describes referred pain; when visceral branch of a pain receptor fiber is stimulated, vasodilation and pain may occur in a distant body area; right shoulder or scapula is the referred pain site for gallbladder (3.) anatomically correct but is not the best explanation (4.) possible; not the best explanation
During an extremely busy time during the shift, a middle-aged client is admitted to the unit with menorrhagia. It is MOST important for the LPN/LVN to instruct the nursing assistant to perform which of the following activities? 1. Ask the client if the vaginal discharge has decreased during the previous 2 hours. 4. Collect the client's sanitary napkins in a plastic bag and to give them to the LPN/LVN.
(1.) not the most accurate assessment; LPN/LVN should directly view quantity of bleeding (4.) CORRECT— enables LPN/LVN to make direct determination about the blood loss; LPN/LVN should validate conclusions with RN
The LPN/LVN assists with the care of a client diagnosed with a closed head injury with increased intracranial pressure. Which action, if performed by the LPN/LVN, is best for this client? 1. Position client with head of bed flat. 3. Maintain propofol IV drip rate
(1.) supine position with a head injury could result in cerebral edema; head should be elevated (3.) CORRECT—propofol is a general anesthetic administered for its paralyzing effect, which reduces cellular metabolic demands, which in turn result in decreased risk of cerebral hypoxia
The LPN/LVN reinforces instructions about a cardiac exercise stress test to the client in the outpatient clinic. Which statement by the LPN/LVN is best? 2. "The cardiac exercise stress test determines the amount of stress your heart can tolerate." 3. "The cardiac exercise stress test determines the adequacy of your peripheral circulation."
(2) CORRECT— during the exercise stress test, the client runs on a motorized treadmill or rides a bike while heart rate and blood pressure are monitored; health care provider can determine if cardiac ischemia is occurring and can get an estimate of the workload or stress this person's heart can tolerate (3) arterial tests include angiography, exercise test for intermittent claudication; venous tests include phlebography, ultrasonic flow detection
Because of specific physiological changes in clients with cirrhosis, the home care LPN/LVN teaches the family that the client should include the following nutrients in the daily diet? 2. Increased protein and increased carbohydrates. 3. Increased calcium and decreased fat.
(2) CORRECT—because many alcoholics are malnourished, a high-protein diet is important (3) no change in calcium; moderate amounts of fat allowed
During shift report, a LPN/LVN is informed that a new client with a history of alcoholism and cirrhosis is included in the assigned group of clients. The LPN/LVN anticipates that the client will have which of the following characteristics? 2. The client has atrophy of the muscles. 4. The client is morbidly obese.
(2) CORRECT—decreased liver function results in decreased protein metabolism, resulting in decreased muscle mass; indications of cirrhosis include jaundice, pruritus, ascites, anorexia, weight loss, increased bleeding tendencies (4) if weight is greater than expected for height, will be related more to ascites than body mass
An LPN/LVN cares for the client managing chronic kidney disease by utilizing peritoneal dialysis. Which nursing action should the LPN/LVN take first? 2. Warm the dialysate. 4. Insert a Foley catheter.
(2) CORRECT—dialysate should be warmed to body temperature to prevent disruption of tissue temperature; weigh client before and after dialysis; dialysate is infused into peritoneal cavity and then drained from abdomen after prescribed amount of time (4) a catheter is implanted in the abdomen
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? 2. The staff member holds onto the outer surface of the facemask while pulling mask away from face. 4. The staff member washes her/his hands for 15 seconds.
(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 (4)appropriate action; handwashing is the BEST preventive measure for controlling the spread of infection
Following the insertion of a central venous pressure line with IV 1000 mL D 5 in .45 normal saline at 100 mL/hour, the client reports dyspnea and chest pain. The LPN/LVN understands that the most probable cause of these symptoms includes which reason? 2. Pneumothorax. 3. Sudden drop in cardiac output.
(2) CORRECT—pneumothorax is a potential complication of the insertion of any central venous pressure line, especially a subclavian line; because of the proximity of the central veins and the lung cavity, pneumothorax can occur from perforations of the pleura by the catheter; pneumothorax is collapse of a lung caused by air in pleural space; symptoms include pain and respiratory distress; should also assess for dysrhythmic chest movement (3) first response to sudden drop in cardiac output is more likely to be cerebrovascular and cardiovascular
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? 2. Abstain from unprotected sexual intercourse. 3. Use special disinfectant in toilet.
(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
A 4-month-old infant is seen in the well-child clinic. The LPN/LVN is MOST concerned if which of the following is observed? 2. The infant's head lags when pulled from a lying to a sitting position. 3. The infant is drooling.
(2) CORRECT—should observe almost no head lag at 4 months (3) appropriate behavior
Which laboratory finding should the LPN/LVN expect if a client has fluid volume deficit? 2. Specific gravity 1.034. 3. Potassium 5.8 mEq/L
(2) CORRECT—specific gravity >1.030 indicates possible fluid volume deficit; specific gravity refers to the weight of urine in relation to distilled water (1.000); weight of particles per volume of urine is the specific gravity; during dehydration the body conserves fluid, resulting in more particles per volume of fluid, which results in more concentrated urine (3) normal potassium is 3.5 to 5.0 mEq/L; hyperkalemia is often caused by chronic kidney disease; not commonly associated with fluid loss
The LPN/LVN identifies which sign or symptom as an early indication of extracellular fluid volume excess? 2. Watery diarrhea. 3. Bounding pulse.
(2) may be caused by overhydration from water intoxication (3) CORRECT—cardiovascular response to excess fluid volume is likely to occur before edema occurs; because the cerebral cells are more sensitive to fluid volume excess, the earliest signs/symptoms are cerebral
A client diagnosed with bipolar disorder is hospitalized in the elation phase of the illness. The client says to the LPN/LVN, "Even though I don't have a job, I just bought myself a home computer and a large screen TV for my family." Which interpretation by the LPN/LVN is most accurate? 2. The client has an increased need to manipulate electronic devices. 4. The client has a mood disturbance and judgment is poor at this time.
(2) unrestrained buying sprees are common; not necessarily related to any particular type of item (4) CORRECT—person in a manic state may have delusions of grandeur and/or an exalted opinion of himself and his abilities; can be manipulative, testing, and demanding due to poor self-esteem
The LPN/LVN assists in the management of the health care of an older adult client suspected of having syndrome of inappropriate antidiuretic hormone (SIADH). The LPN/LVN is MOST concerned if which of the following is observed? 2. The client is drinking water. 4. The client is lying in bed with the rails up.
(2.) CORRECT— SIADH causes a dilutional hyponatremia; water intake monitored closely (4.) implement safety measures to prevent injury caused by potential changes in level of consciousness
The LPN/LVN receives patient assignments from the charge nurse and prepares to make rounds on the assigned patients. Which of the following patients should the LPN/LVN see FIRST? 2. A patient 3 days post right-knee replacement complaining of right calf pain with movement. 3. A patient drinking contrast for an abdominal CT scan and complains of nausea.
(2.) CORRECT— assess for possible DVT, report immediately to supervising nurse; possibility of a blood clot that not only impacts circulation, but also the potential to impact the patient's respiratory status, takes precedence (3.) although symptom management is important to patient comfort and to insure the patient is able to complete the contrast for the test, a potentially life-threatening condition takes precedence
The LPN/LVN cares for an older adult. To help the client plan for the future, which of the following actions by the LPN/LVN is MOST important? 2. Provide the client an opportunity to reminisce about past events. 4. Help the client set priorities for the future.
(2.) CORRECT— reviewing past events helps the client find self-worth; examining what has been accomplished and what can be accomplished in the future allows the nurse to help client plan for future (4.) assessment is needed before setting priorities
The LPN/LVN prepares a client for a total hip replacement. Which of the following observations by the LPN/LVN necessitates contacting the physician? 2. The client complains about burning on urination. 4. The client's platelet count is 250,000/mm 3.
(2.) CORRECT—indicates urinary tract infection; an infection from any source in the body is a contraindication in any preoperative client but especially in clients having skeletal surgery, such as a total joint replacement (4.) normal range: 150,000 to 400,000/mm 3
Which nursing intervention, if performed by the LPN/LVN, is most appropriate for a client with rheumatoid arthritis? 2. Position the client on the abdomen several times a day. 4. Assist with heat application and range-of-motion exercises.
(2.) is recommended if client can tolerate position; prevents flexion (4.) CORRECT—the goals of these interventions are to reduce swelling, increase circulation, and diminish stiffness while preserving joint mobility; this is critical for a client with rheumatoid arthritis
The LPN/LVN cares for clients In a long-term care facility. The LPN/LVN teaches the nursing assistants how to maintain the patency of feedings tubes. It is MOST important for the LPN/LVN to demonstrate which of the following? 3. Irrigate with 30 to 50 mL when feeding is complete. 4. Elevate the head of the bed before initiating the procedure.
(3) CORRECT—flushes from the tube feeding that has large amount of protein sediment, which will adhere to tubing and result in obstruction of the lumen (4) prevents reflux or aspiration of feeding
The LPN/LVN cares for a client diagnosed with acute kidney injury. The client's family shares with the LPN that the client does not want to maintain bedrest. Which response by the LPN/LVN is best? 3. "Bedrest will reduce the body's metabolic rate." 4. "The client's serum calcium is high, which places the client at risk for seizures."
(3) CORRECT—goal is to reduce the demand on the impaired kidney; function can improve with acute kidney injury (4) because phosphate levels are high, calcium levels tend to be high; may have seizures during the oliguric phase, but is not the reason for bedrest
A child who is 5 and a half years old comes to the clinic for a routine examination. The child's mother reports that the child likes to jump and climb, questions everything, and is often observed interacting with an imaginary best friend. The LPN/LVN should advise the mother to take which of these actions? 3. Allow the child to engage in imaginary play. 4. Never leave her child alone.
(3) CORRECT—having imaginary friends is a normal and common occurrence in children between the ages of 4 and 6; usually by the time the child is 6, he or she outgrows the imaginary friend (4) should reassure the parent that this is normal behavior
The LPN/LVN initiates the discharge plan developed by the assigned nurse for the family of a client diagnosed with hepatic encephalopathy. Further teaching is necessary if the family makes which of the following statements to the LPN/LVN? 3. ʺOur parent should eat meat at every meal.ʺ 4. ʺLactulose may cause bloating and cramps.ʺ
(3) CORRECT—low-protein, high-calorie diet; instruct family to observe for and report mental changes (4) side effect of medication; lasts about a week and then disappears
The LPN/LVN cares for a client with cancer receiving chemotherapy. The client shares with the LPN/LVN how upset she is that she is losing her hair. Which of the following statements by the LPN/LVN is BEST? 3. "Your hair will grow back about one month after chemotherapy is complete." 4. "There are many attractive hats and scarves that will look very good on you."
(3) CORRECT—reassure client that hair loss is temporary; new hair may be a different color, texture, and thickness (4) therapeutic communication reflects client's feelings and/or gives information; this response offers client a solution
A client delivers a healthy, 8-lb, 2-oz boy. the client asks the LPN/LVN how to care for the baby's ʺsoft spot.ʺ It is most appropriate for the LPN/LVN to teach the client about which information? 3. If the soft spot bulges during coughing, notify clinic at once. 4. Except for gentle cleansing, avoid handling the area.
(3) coughing or crying can causes anterior fontanel to bulge (4) CORRECT—would be appropriate to cleanse without applying excessive pressure to the area
Which of the following fears is most important for the LPN/LVN to consider when caring for a 4-year-old who is about to have surgery? 1.Fear of separation. 4. Fear of mutilation.
(3)fear of toddler; teach parents to expect regression (4) CORRECT—preschool children are frightened of invasive procedures because they fear mutilation; allow child to play with models of equipment; encourage expression of feelings
The LPN/LVN learns during the change-of-shift report that a client with a "do not resuscitate" advance directive was resuscitated by a nursing assistant. To prevent this from happening again, it is MOST important for the LPN/LVN to recommend which of the following to the supervising nurse? 3. Attach a small blue banner to appropriate clients' bedside stands and wheelchairs. 4. Check the client's chart before initiating resuscitation.
(3.) CORRECT— staff would recognize that the client has advance directive; errors could still occur but this will reduce the risk (4.) need a way to provide immediate communication of the information so that staff can initiate CPR on clients without advance directives
the LPN/LVN cares for a preoperative client diagnosed with a detached retina. Which action is most appropriate? 3. Maintain the client on bedrest. 4. Position the client on the unaffected side.
(3.) CORRECT—minimizes movement of the eyes and head to facilitate settling of the detached retina; goal is to bring the two ends together (4.) area of detachment should be in dependent position
While teaching a client with a below-the-knee amputation to care for the residual limb at home, the LPN/LVN should advise the client to take which action? 3. Keep the residual limb elevated. 4. Expose the residual limb to air.
(3.) because extensors are stronger than flexors, elevation of stump could result in contractures (4.) CORRECT—air exposure will facilitate healing of the residual limb
The LPN/LVN completes a health history form for a family living in a home built during the 1920s. The LPN/LVN informs the family that which of the following manifestations are TYPICAL of lead poisoning? 1. Anemia, hearing impairment, distractibility. 2. Tinnitus, confusion, hyperthermia.
1) CORRECT—also includes irritability, sleepiness, nausea, vomiting, abdominal pain, increased intracranial pressure; treatment includes chelation (2) associated with aspirin poisoning
The LPN/LVN identifies which signs and symptoms as most representative of the signs and symptoms commonly observed in a client who has recently taken heroin? 1. Constricted pupils, depressed respirations. 2. Dilated pupils, increased respirations.
1) CORRECT—client who has recently taken heroin will have the CNS-depressed effects of constricted pupils and slow, shallow breathing (2) signs/symptoms are representative of CNS stimulation
The clinic LPN/LVN is assisting a client manage the challenges of the diagnosis of hepatitis B. Which is most important for the LPN/LVN to encourage the client to discuss with the health care provider? 1. Serum anti-delta antibodies. 2. Thorough hand washing after evacuation of stool
1) CORRECT—clients with hepatitis B are prone to develop hepatitis D; antibodies for the delta virus confirms the diagnosis (2) is transmitted via contact with blood
The LPN/LVN cares for an older client admitted to the hospital with persistent vomiting and abdominal pain. After the nasogastric tube in the left nostril is connected to suction, an intravenous infusion of 1,000 mL of D 5W with 20 mEq/L of potassium chloride (KCl) is initiated at 100 mL per hour. The LPN/LVN understands KCl has been added to the infusion for which reason? 1. To replace the potassium lost in the gastric fluid. 3. To prevent the loss of sodium in the urine.
1) CORRECT—gastric contents are high in KCl; any process resulting in excessive loss of this fluid can cause hypokalemia; lost KCl by way of persistent vomiting and continues to lose by way of the NG tube; symptoms of hypokalemia (<3.5 mEq/L) include muscle weakness, paresthesias, and dysrhythmias 3) because GI secretions are hypotonic, sodium level remains at the same level during NG suction or vomiting unless other factors are contributing to Na + loss or concentration; Na + and K + have an indirect relationship in which K + increases as sodium decreases
The spouse of a client in the advanced stages of Parkinson's disease tells the LPN/LVN of becoming weary of the daily, seemingly insurmountable tasks required to maintain the spouse's health. Which action by the LPN/LVN is best? 1. Assist the spouse to plan time for individual needs. 4. Help the spouse identify the particular part of the care that causes weariness.
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 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
The LPN/LVN suspects that a child has been abused by her mother and plans to report this to the supervising nurse. After the LPN/LVN tells the mother about the need to do this, the mother bursts into tears. Which of the following responses by the LPN/LVN is BEST? 1. "I can see you are very upset about this." 3. "Tell me about how things have been going at home."
1) CORRECT—responds to the mother's behavior; the LPN/LVN is responding to the feeling tone of the mother's behavior (2) because question is about therapeutic communication, important to reflect patient's feelings (3) assessing the situation, which is the second best answer
The LPN/LVN cares for a client diagnosed with cirrhosis. After reviewing the record, what lab value should the LPN/LVN report to the supervising nurse? 1. Serum albumin 4.0 g/dL. 3. Serum alanine aminotransaminase (ALT, SGPT) 600 units.
1) albumin synthesis depends on normal liver function; normal is 3.5-5.5 g/dL; decreased in liver disease (3) CORRECT—elevation indicates serious liver damage; normal is 5-35 units
A client is scheduled for bowel surgery, and the health care provider orders a low-residue diet as a part of the bowel preparation. The LPN/LVN reinforces teaching to the client about foods allowed on a low-residue diet. The LPN/LVN determines teaching is effective if the client chooses which menu? 1. Bouillon, grilled cheese sandwich, and grapes. 3. Roast lamb, buttered rice, and sponge cake.
1) grapes are not allowed on low-residue diet because of the skin on grapes (3) CORRECT—foods allowed include well-cooked tender meats (roast lamb), fish, and poultry; milk and mild cheeses; juices without pulp (no prune juice); canned fruit and firm bananas; white bread or refined bread
The LPN/LVN cares for a client diagnosed with chronic cholecystitis. While the client waits for the prescribed medication to dissolve the gallstones, it is MOST important for the LPN/LVN to monitor which of the following? 1. Increased serum amylase, lipase, and glucose levels. 2. Frequent bruising.
1) indicative of pancreatitis (2) CORRECT—bile acids required for metabolism of fat-soluble vitamins such as A, D, E, and K; primary signs/symptoms include bruising related to insufficient levels of vitamin K, which is required for synthesis of vitamin K-dependent clotting factors; indications of cholecystitis include intolerance to fatty foods, indigestion, nausea, vomiting, flatulence, eructation, severe pain in upper right quadrant of abdomen radiating to back and right shoulder
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. 3. Purchase protective devices such as headgear and kneepads.
1) parents need assistance on how to meet the child's needs without putting him at risk (3) CORRECT—will allow child to perform developmental tasks without being at risk for injury
A 5-year-old is scheduled for a tonsillectomy and adenoidectomy. The child is given midazolam (Versed) preoperatively. The LPN/LVN understands that the purpose for administering this medication includes which of the following? 1. Decrease the child's gag reflex. 2. Decrease the child's psychological responses
1)more common with topical Xylocaine (2) CORRECT—reduces anxiety and causes amnesia and sedation; is excellent for use in children because of short duration and rarely causes respiratory depression
The LPN/LVN cares for a client newly diagnosed with Parkinson's disease. The LPN/LVN expects to observe which of the following? 1. Tremors. 2. Diplopia. 3. Bradykinesia. 4. Slurred speech. 5. Respiratory distress. 6. Propulsive gait.
1.) CORRECT— resting tremor that disappears with purposeful movements (2.) occurs with myasthenia gravis (3.) CORRECT— abnormally slow muscle movement; has trouble initiating movement (4.) CORRECT — caused by weakness and incoordination of muscles (5.) occurs with myasthenia gravis (6.) CORRECT— instruct client to walk erect, watch the horizon, and use a wide-based gait
The LPN/LVN observes the unlicensed assistive personnel assisting a client diagnosed with a right-sided CVA with a bed bath. The LPN/LVN should intervene if the nursing assistant performs which of the following activities? Select all that apply: 1. The nursing assistant raises the bed to the appropriate level. 2. The nursing assistant reaches over the bedrail to bathe the client. 3. The nursing assistant initially removes the client's pajama top from the client's right side. 4. The nursing assistant first washes the client's feet. 5. The nursing assistant allows the client to wash the affected arm. 6. The nursing assistant applies body lotion to the client.
1.) appropriate action; decreases strain on the nursing assistant (2.) CORRECT— lower side rail closest to nursing assistant to prevent strain on nursing assistant's back muscles (3.) CORRECT — remove the clothing from the unaffected side first (4.) CORRECT — begin with client's face (5.) appropriate behavior; allow client as much independence as tolerated (6.) appropriate action; prevents development of dry skin
The LPN/LVN cares for a client diagnosed with aphasia after a stroke. The LPN identifies the primary problem of a client with aphasia is likely to be which problem? 1. Inability to understand others. 3. Social isolation.
1.) depends on the type of aphasia; if client has receptive aphasia, will have difficulty understanding spoken and written language; clients with expressive aphasia understand what is being said but have difficulty verbally communicating; client can also have global or mixed aphasia, which is a combination of receptive and expressive aphasia (3.) CORRECT—common social reactions to aphasia are frustration, depression, and isolation
The LPN/LVN cares for a middle-aged adult diagnosed with Buerger disease. The client's spouse and adolescent children begin working to meet the family's financial needs. During a home visit, it is most important for the LPN/LVN to report which finding to the supervising nurse? 2. At times, the client is verbally abusive to his spouse. 4. The client is withdrawn and sleeps most of the day.
2) CORRECT— without intervention, verbal abuse can progress to physical abuse; can migrate to the children also 4) illustrates signs/symptoms of clinical depression, which is common following a significant loss
An 18-month-old toddler with cystic fibrosis is admitted to the hospital with a respiratory infection. Which is one of the most significant nursing interventions the LPN/LVN will need to implement? 2. Report sodium levels. 4. Assist in maintaining growth and development.
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 (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
The LPN/LVN makes a home visit to a client at 29 weeks gestation diagnosed with type 1 diabetes mellitus. The client states that she has been nauseated for 24 hours. It is MOST important for the LPN/LVN to ask which of the following questions? 2. "What was your last blood glucose reading?" 3. "Have you taken your insulin today?
2) current blood glucose reading required for accurate assessment (3) CORRECT important that client take prescribed insulin even though may not be eating regularly, because insulin needs are increased during illness
The LPN/LVN cares for a client 3 days after a complete cystectomy and ileal conduit. Which observation would cause the LPN/LVN to contact the supervising nurse? 2. The stoma appears red in color. 3. The stoma appears edematous.
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 health care provider 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
A client with type I diabetes is scheduled for a right below-the-knee amputation due to a gangrenous toe. The client asks the LPN/LVN why the amputation needs to be so extensive. Which of the following responses by the LPN/LVN is BEST? 2. "To provide for the appropriate amount of circulation needed for healing." 3. "To facilitate the earliest possible prosthetic training."
2.) CORRECT—the level of an amputation is based on the adequacy of circulation; to leave tissues that are poorly supplied with blood would cause poor healing and could lead to the repeated development of gangrene (3.) may be fitted with temporary prosthesis at the time of surgery; not related to rationale for determining location of amputation; early and late prosthetic training is based on philosophy of health care provider
The LPN/LVN cares for a client with a tracheostomy. The LPN/LVN notes the client produces copious amounts of secretions, resulting in frequent airway obstruction. Because the client becomes extremely anxious, which intervention by the nurse is most appropriate? 2. Elevate the head of the bed to 45 degrees. 3. Assure client the nurses will keep the airway patent.
2.) head of bed should remain elevated; just elevating the of head of the bed when the airway is obstructed would do little to relieve anxiety (3) CORRECT— frequently reassuring client that nurses will maintain an open airway and suctioning when needed will do more to lower anxiety level than other activities
The LPN/LVN cares for clients in the long-term care facility. After receiving report, which of the following clients should the LPN/LVN see FIRST? 2. A client due to receive a metered dose inhaler (MDI). 4. A client who has been verbally abusive to staff and is becoming increasingly more agitated.
2.) safety takes precedence over administration of routine; non-emergent medications (4.) CORRECT— client poses a potentially immediate physical threat to himself, staff members, and/or other clients and visitors if the situation is allowed to escalate further; intervene and initiate protocols prescribed by the individual facility to maintain a safe environment
When assisting in the formulation of the nursing care plan for a client following a myocardial infarction, the LPN/LVN expects which goal to be included? 3. The client will be free from pain and dysrhythmias. 4. The client will eliminate all stress from the lifestyle.
3) CORRECT—this goal is realistic, achievable, and measurable (4) want client to learn how to cope with stressors in life; goal is not feasible
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)? 3. Increase urinary bladder capacity. 4. Prevent clot formation.
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 counsels the mother of a child diagnosed with attention deficit disorder (ADD). Which statement by the nurse is most appropriate? 3. "Limit the number of toys and materials that you offer your child." 4. "Hug your child after a task is correctly performed."
3) consistency is important to the success of a child diagnosed with ADD 4) CORRECT — child diagnosed with attention deficit disorder is often an underachiever in school and may display impulsive, aggressive, and hostile behavior; child responds to positive reinforcement
The LPN/LVN supervises nursing assistants caring for clients in the long-term care facility. The LPN/LVN instructs a nursing assistant to give comfort to a client by providing a massage. The LPN/LVN should include which of the following instructions? Select all that apply: 1. " Massage any reddened areas you see on the client's skin." 2. " Massage the client's back." 3. " Report to me if you see any reddened areas on the client's back." 4. " Massage the client's leg and calf muscles." 5. " Assess the client's back before beginning the massage." 6. " Place the lotion in a container of warm water."
Determine the outcome of each answer. Is it desired? (1.) do not massage reddened areas (2.) CORRECT— instruct the nursing assistant about which part of body to massage (3.) CORRECT — part of appropriate delegation; LPN/LVN should assess for any contraindications to the client receiving a back massage (4.) do not massage leg and calf muscles; massage back, neck, arms, hands, and feet (5.) responsibility of LPN/LVN to assess client; nursing assistants perform standard, unchanging procedures (6.) CORRECT— increases client's comfort level by using warmed lotion; can also warm a small amount of lotion in the nurse's hands
The nurse performs a physical assessment of the precordium on an adult male. Identify where the nurse should place the stethoscope to auscultate Erbs' point.
Erb's point is located in the third intercostal space just to the left of the sternum; both aortic and pulmonic murmurs may be auscultated at this location.
The nurse cares for toddlers in the pediatric clinic. The nurse discusses developmental milestones with the parent of a toddler. Arrange the following developmental milestones in the proper order. All options must be used Building a tower of three to four blocks Using two- to three-word Walking without help Jumping with both feet
Picture a toddler. (1) Walking without help begins at 13-15 months (2) Building a tower of three to four blocks occurs at 18 months (3) Using two- to three-word phrases occurs at 24 months (4) Jumping with both feet occurs at 30 months
The LPN/LVN in the long-term care facility cares for a client diagnosed with heart failure. The LPN/LVN expects to observe which of the following? Select all that apply: 1. Dependent edema. 2. Pleuritic pain. 3. Dyspnea. 4. Chest pain. 5. Tachycardia. 6. Bleeding tendencies.
Think about each answer. (1.) CORRECT— indicates right-sided failure (2.) seen with pleurisy and pneumonia (3.) CORRECT— shortness of breath, labored breathing (4.) seen with angina or myocardial infarction (5.) CORRECT— decrease in ejected ventricular volume causes sympathetic nervous system to increase the heart rate (6.) not seen with heart failure; may occur if client is on an anticoagulant
The LPN/LVN supervises a nursing assistant caring for a client receiving enteral feeding via a nasogastric tube. The LPN/LVN determines that care is appropriate if which of the following is observed? Select all that apply: 1. The nursing assistant aspirates and measures the amount of the gastric aspirate. 2. The nursing assistant elevates the head of the client's bed 30 degrees. 3. The nursing assistant warms the formula to room temperature. 4. The nursing assistant measures the pH of the gastric aspirate. 5. The nursing assistant infuses the intermittent feeding in 20 minutes. 6. The nursing assistant clamps the proximal end of the feeding tube at the end of the feeding.
Think about each answer. (1.) verifies placement of the tube and should be performed by licensed personnel (2.) CORRECT — prevents aspiration (3.) CORRECT — prevents cramping (4.) should be performed by licensed personnel (5.) should infuse for a minimum of 30 minutes (6.) CORRECT— prevents air from entering the stomach
