K pn 2018- 6

The home care LPN/LVN cares for a client diagnosed with heart failure. The home care nurse anticipates this client might experience which type of edema? 2. Dependent. 4. Severe.

(2) CORRECT—seen with right-sided heart failure and usually noted in the ankles and in the sacral region (4) can be mild, moderate, or severe; related to degree of cardiac impairment

A client undergoes a transurethral resection of the prostate (TURP). In the immediate postoperative period, which characteristic should the LPN/LVN expect when observing the urinary drainage? 1. Bloody. 3. Clear.

1) CORRECT—procedure causes bleeding, therefore the urine would be bloody; a large-size catheter is used to facilitate the removal of clots from the bladder (3) urine is normally clear, transparent, and yellow in color

The LPN/LVN interacts with the parents of a child with Down's syndrome. Which of the following statements, if made by the parents to the LPN/LVN, indicates further teaching is necessary? 1. "My child's development will become more rapid in time." 2. "My child's motor skills will always be slow." 3. "Play is a good way to teach my child." 4. "My child responds to affection."

Strategy: "Further teaching is necessary" indicates incorrect information. (1) CORRECT—usually mildly to moderately retarded; socially may be 2 to 3 years beyond mental age (2) motor skills may be delayed due to hypotonicity (3) children involved in early stimulation programs that provide physical therapy to help children learn motor skills (4) all children respond to love and affection

The LPN/LVN cares for an African American client with a history of chronic kidney disease. The client reports tingling around the mouth and muscle spasm in the fingers. It is most important for the LPN/LVN to perform which activity? 1. Assess the client's ability to swallow. 4. Set up seizure precautions for the client.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1.) although tingling around oral cavity occurs, hypocalcemia does not affect the ability to swallow 4.) CORRECT— hypocalcemia can result in seizures

The LPN/LVN implements the discharge plan initiated by the RN for a client diagnosed with active tuberculosis. Which instruction 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." 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 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

The LPN/LVN instructs a client in the outpatient clinic about probenecid (Benemid). It is MOST important for the LPN/LVN to make which of the following statements? 1."Drink at least 6 to 8 glasses of water each day." 2. "Take the medication on an empty stomach." 3. "You may take aspirin for minor pain." 4. "You are permitted to drink wine with dinner."

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1.) CORRECT—probenecid (Benemid) is an antigout medication that increases the excretion of uric acid; increased fluids will increase the excretion of uric acid (2.) take with milk, food, or antacids to decrease GI distress (3.) because of compounded side effects, clients with gout should avoid all products containing aspirin (4.) avoid alcohol because it increases urate levels

During a routine prenatal visit, the nurse assesses a client at 38 weeks' gestation. The nurse auscultates the fetal heart rate (FHR) and notes that the fetal position is left occiput anterior (LOA). Identify the point of maximum intensity of the fetal heart tone.

Strategy: Identify the mother's left side. LOA indicates vertex is the presenting part with fetal occiput on the mother's left side toward the front of her pelvis; because infant is vertex, FHT heard below the umbilicus.

The nurse auscultates the fetal heart rate (FHR) and notes that the fetal position is right occiput anterior (ROA). Identify the point of maximum intensity of the fetal heart tone.

Strategy: Identify the mother's right side. ROA indicates vertex is the presenting part with fetal occiput on the mother's right side toward the front of her pelvis; because infant is vertex, FHT heard below the umbilicus.

The LPN/LVN cares for a 4 lb, 10 oz infant delivered at 32 weeks' gestation. The LPN/LVN notes that the infant has mottling of the skin, and lab values indicate metabolic and respiratory acidosis. The LPN/LVN recognizes that these findings are signs of which of the following? 1. Respiratory distress syndrome. 2. Cold stress.

Strategy: Think about each answer. (1) altered respiratory state due to surfactant deficiency in lungs; labored respirations after several minutes or hours of normal respirations initially; cyanosis, grunting, nasal flaring, retractions, tachypnea (2) CORRECT excessive loss of heat that results in increased respirations and nonshivering thermogenesis; metabolic acidosis occurs; place in heated environment

Identify where the nurse should place the stethoscope to auscultate the aortic area.

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

The LPN/LVN identifies that which of the following changes in the pattern of urinary elimination is usually associated with aging? 2. Incontinence. 3. Sphincter reflexes decrease

(2)not a normal change associated with aging; stress incontinence can be a problem due to decreased urinary sphincter tone; men may experience overflow incontinence due to BPH (3) CORRECT—decrease in sphincter reflexes is a physiological change that often occurs with advanced age

The LPN/LVN knows that nocturnal emissions refer to which of the following? 1. Secretion of vaginal fluid while asleep. 3. Loss of seminal fluid by an adolescent while asleep.

(1) physiological leukorrhea occurs early in puberty; reassure girls and their parents that this is not a sign of vaginal infection (3) CORRECT—nocturnal emissions (loss of seminal fluid during sleep) are found in the adolescent male

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. 3. Take the child to the emergency room.

(1) regardless of the vital-sign range, can offer no treatment (3) CORRECT—due to length of illness, child should be seen by health care provider

The home care LPN/LVN visits a client 4 days after a transsphenoidal hypophysectomy. The LPN/LVN should intervene if which is observed? 1. The client bends the knees to pick up shoes. 3. The client brushes teeth morning and night.

(1) surgery involves excision or removal of the pituitary; should avoid bending over with head lower than trunk, reduces potential for increased intracranial pressure (3) CORRECT—not allowed to brush teeth for 1 to 2 weeks to allow incision to heal; instruct client to floss and use mouthwash

The LPN/LVN finds a client diagnosed with schizophrenia standing in the dayroom of the psychiatric inpatient unit completely undressed. Which measure by the LPN/LVN is best? 1. Cover the client with a towel or sheet and send client back to get dressed. 2. Lead the client back to the client's room and help the client get dressed

(1) this behavior indicates that the client is experiencing a crisis; schizophrenics have difficulty processing information; may not be able to sequence the steps required to get dressed (2) CORRECT—the immediate nursing action is to take the client back to his room and get him dressed; the behavior reflects regression common in schizophrenic clients

When assessing the abdomen, the LPN/LVN should place the client in which of the following positions? 1. Supine. 2. Supine with knees flexed.

(1)flat on back; position to avoid hip flexion (2) CORRECT—relaxes muscles and provides for comfort

The LPN/LVN tests the pH of a child's urine. The LPN/LVN expects which finding? 1. pH 3.4. 2. pH 6.0. 3. pH 8.2. 4. pH 8.5.

(1)too acidic; pH affected by diet, medications, infections, acid-base balance, and altered kidney function (2) CORRECT—range for pH of urine is 4.5 to 8; tends to be primarily acidic; helps protect against bacterial infection (3)too alkaline (4)too alkaline; if urine specimen stands for several hours, will become alkaline

A client diagnosed with acute kidney injury asks the LPN/LVN why the dietary recommendations include high carbohydrate content with low protein content. Which response by the LPN/LVN is best? 1. "Carbohydrates are utilized for energy first." 3. "A high-carbohydrate, low-protein diet reduces the need for kidney dialysis."

(1) CORRECT—because carbohydrates are metabolized first, the accumulation of protein by-products is reduced; impaired or damaged kidneys cannot adequately break down or excrete protein by products (3) dialysis may be needed even if client follows the proper diet

The home care LPN/LVN cares for a client diagnosed with acute myelogenous leukemia. The client's temperature is 101.0°F (38.3°C). Which of the following actions should the LPN/LVN take FIRST? 1. Notify the physician. 2. Offer the client oral fluids.

(1) CORRECT—client is immunocompromised and at risk for infection; obtain temperature q 4 h; inspect wounds, skin, and mucous membranes for redness, swelling, and drainage; notify physician immediately so that appropriate treatment can be started (2) hydration is important, but more important to notify physician

he LPN/LVN cares for a client diagnosed with leukemia. The client tells the LPN/LVN that he is having abdominal pain. The LPN/LVN understands that the abdominal pain is due to which of the following? 1. Hepatosplenomegaly. 3. Persistent vomiting.

(1) CORRECT—clients with leukemia develop enlarged liver and spleen, causing the abdominal pain (3)may occur due to chemotherapy; administer an antiemetic

The LPN/LVN understands that psoriasis is which of the following? 1. A chronic hereditary disease. 2. An acute infectious disease.

(1) CORRECT—psoriasis is a lifelong scaling skin disorder with underlying inflammation, characterized by exacerbations and remissions; usually a family history of psoriasis (2)microorganisms do not cause this disease; the cause is unknown; improves in warmer climates

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

(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 (3) more frequent feedings are appropriate when GI tract is irritated or inflamed

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. 4. Obtain vital signs.

(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 (4) vital signs are altered by the increased hormone level but would not add to database to aid LPN/LVN in appropriate decision making

The LPN/LVN makes a home visit to a client receiving chemotherapy for the treatment of cancer. The LPN/LVN instructs the client about ways to avoid injury due to bone marrow suppression. The LPN/LVN should intervene if which of the following is observed? 1. The client takes Alka-Seltzer for indigestion. 4. After bumping the leg, the client applies ice for 30 minutes.

(1) CORRECT—should not take medications that contain aspirin due to danger of bleeding; Alka-Seltzer contains aspirin (4) appropriate action; instruct not to participate in contact sports

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

(1) CORRECT—this is the route to be used for the Mantoux test; the substance used in the Mantoux test 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

The LPN/LVN should lubricate the catheter used to suction a client's tracheostomy with which of the following? 1. Sterile water. 4. K-Y jelly.

(1) CORRECT—water is the preferred lubricant because it won't irritate the tissues; can also use sterile saline (4) is water-soluble lubricant in gel form, introducing catheter covered with gel could result in aspiration of the material

The LPN/LVN suctions a client by way of the tracheostomy. When performing this procedure, in which position should the client's head be placed to clear the right bronchus of debris? 1. The client's head turned to the left. 2. The client's head turned to the right

(1) CORRECT—when a tracheostomy client is suctioned, the head should be positioned to the side opposite from that of the bronchus being suctioned; clearing the right bronchus is therefore best accomplished by turning client's head to the left (2) appropriate position to suction the left bronchus

The LPN/LVN assists in the care of clients in the pediatric clinic. The mother of a young child asks the nurse why play therapy is offered to children. Which of the following statements by the LPN/LVN is BEST? 1. "Young children have difficulty verbalizing thoughts and emotions." 3. "Play is an enjoyable form of therapy for children."

(1) CORRECT—young children are not able to conceptualize their feelings and put them into words; play is how they express themselves; play therapy is the most effective way for the nurse to enter the child's world (3) provides an avenue for children to explore and express thoughts and feelings

In order to prevent parent-child disturbances, it is MOST important for the LPN/LVN to take which of the following actions? 1. Report potential abuse to the appropriate authorities. 2. Discuss with the parents any problems or fears about child rearing that they may have.

(1) all health care professionals are required by law to report child abuse; warning signs of abuse include physical evidence of abuse, confiding stories about the injury, injury is inconsistent with the story; question is about how to prevent parent-child disturbances (2) CORRECT—important that parents become active listeners, become actively involved in children's education, and look at things from child's point of view

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. 3. Soiled linens are placed in a laundry hamper.

(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 (3) CORRECT—keep soiled laundry in a plastic bag

The LPN/LVN understands the purpose of a femoropopliteal bypass is best described as which purpose? 1. Excise the vessel. 2. Insert a graft.

(1) if graft is autogenous, vein is excised (2) CORRECT—in a bypass procedure, a graft is placed and anastomosed distally and proximally to bypass the obstruction

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.

(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

A young adult is admitted to the hospital with a diagnosis of catatonic schizophrenia. When the LPN/LVN places the client's hand over his head, it remains in that position. The LPN/LVN understands that this is a description of which of the following? 1. Conversion hysteria. 2. Waxy flexibility.

(1) motor or sensory neurological symptoms with no identifiable physiological cause (2) CORRECT—waxy flexibility is the term used to describe the abnormal posturing of the catatonic; in catatonia, there is a sudden loss of animation and a tendency to remain motionless in a stereotyped position

The LPN/LVN carries out the teaching plan for a client undergoing nasal surgery. The LPN/LVN instructs the client not to blow the nose after surgery. The client asks the LPN/LVN to explain why. Which explanation by the LPN/LVN is most appropriate? 1. "Blowing your nose will increase intracranial pressure." 3. "Blowing your nose may cause bruising and edema

(1) nasal surgery results in edema and obstructed airway; blowing the nose would result in increased sinus pressure, resulting in increased pressure on the operative site; does not increase intracranial pressure unless intracranial neurological problem exists 3) CORRECT—the increased pressure can cause bruising and edema and damage to surgical area

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." 3. I've heard you can't get rid of gonorrhea. It comes back over and over again.

(1.) CORRECT— gonorrhea causes pelvic inflammatory disease, one of the most common causes of sterility; gonorrhea is treated with antibiotics (3.) episodes are self-limiting with ingestion of antibiotics; should avoid sexual activity until infection is cured; is more indicative of genital herpes

An LPN/LVN follows a standardized teaching model to instruct a client about birth control methods. The LPN/LVN informs a client that the minimal period of time the client should leave a diaphragm in place after intercourse is which of the following? 1. 6 hours. 2. 8 hours. 3. 10 hours. 4. 12 hours.

(1.) CORRECT— it is necessary for the diaphragm to remain in place for at least 6 hours to be effective in preventing pregnancy; can be inserted up to 6 hours before intercourse, but spermicide must be inserted into vagina with every intercourse; the spermicide commonly used with diaphragms, nonoxynol-9, is effective for at least 6 hours; success rate of this method is 18 to 26%.

The LPN/LVN cares for a patient in labor. The patient's labor progresses with regular contractions until the cervix is dilated 9 cm. The LPN/LVN identifies that the patient is in what stage of labor? 1. First stage. 2. Second stage. 3. Third stage. 4. Fourth stage.

(1.) CORRECT— the first stage is from the beginning of labor until the cervix is completely dilated; divided into phase 1 (latent, 0 to 3 cm), phase 2 (active, 4 to 7 cm), and phase 3 (transition, 8 to 10 cm) (2.) from complete dilatation to the birth of the baby; phase 1, 0 to +2 station; phase 2, +2 to +4 station; phase 3, +4 to birth (3.) delivery of placenta; slight gush of blood and lengthening of umbilical cord (4.) first 4 hours after the delivery of the placenta

The LPN/LVN assists in the preparation of a client scheduled for a total hip arthroplasty related to degenerative joint disease (DJD) of the left femoral head. After surgery, it is most important for the LPN/LVN to position the client's left leg in which position? 1.Abducted with toes pointing upward. 4.Adducted with ankle joint hyperextended.

(1.) CORRECT—major complication of hip replacement is dislocation of the prothesis; maintain abduction by placing pillow between the legs; do not stoop or cross legs (4.) needs to be aligned with the body; adduction applies pressure on the hip joint; can dislocate prosthesis

The LPN/LVN prepares to administer aspirin to the client. With which liquid should the LPN/LVN administer this medication/? 1. A glass of milk. 4. A small amount of water.

(1.) CORRECT—take with food, milk, or a large glass of water to reduce GI upset (4.) take with a large glass of water

The LPN/LVN cares for clients in the gynecological clinic. Which of the following clients should the nurse see FIRST? 1. A 60-year-old female complaining of dry vaginal wall and painful intercourse. 2. A 35-year-old female post-hysterosalpingogram who is experiencing tachycardia and a generalized rash.

(1.) does not require immediate attention; instruct about water-soluble lubricants (2.) CORRECT— an x-ray of the cervix, uterus, and fallopian tubes performed after the injection of a contrast medium; assess for allergy to shellfish or iodine; requires immediate attention because client is having an allergic reaction.

The LPN/LVN knows that an elderly client with a severe hearing deficit is most likely to exhibit which characteristic? 1. Seeks medical attention immediately. 2. Suspicious of other people.

(1.) may not seek medical care right away (2.) CORRECT—a severe hearing deficit may render an elderly client suspicious of other people; client can't communicate well with other people and therefore may become suspicious of them

The LPN/LVN assists in the preparation of a client for a myelogram with an oil-based contrast medium. The LPN/LVN determines teaching is successful if the client states which of the following? 1 "I will lie on a bed while my body is scanned by magnetic energy." 4. "I will have to lie flat for 24 hours."

(1.) representative of magnetic resonance imaging (MRI) (4.) CORRECT—oil-based contrast medium is removed, client must lie flat for 24 hours after procedure

The LPN/LVN in the outpatient clinic instructs a client diagnosed with cholecystitis about the prescribed medications. Which of the following statements, if made by the client to the LPN/LVN, would cause the LPN/LVN to report a positive outcome to the supervising nurse 2 "We eat a lot of broiled fish and chicken." 3. "I can't wait to eat the chocolates my children gave me

(2) CORRECT—broiled lean meats are high in protein and low in fat; cooked fruits, non-gas forming vegetables, bread are also allowed (3) high-fat food and a stimulant; also avoid fried, fatty foods, gravies, nuts, egg yolks.

A half hour after a bone marrow biopsy, the client tells the LPN/LVN that ʺthe RN told me to get up and walk in the hall.ʺ Which response should the LPN/LVN make first? 2. "I'll help you back to your room." 3. "I need to look at the bone marrow aspiration site."

(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

The LPN/LVN is assigned to help a terminally ill elderly woman with her morning bath routine. The client asks, "Why do you bother with me?" Which of the following responses by the LPN/LVN is BEST? 2. "I care about you and how you are doing." 3. "I understand how you feel."

(2) CORRECT—client may have to come to terms with the fact that he/she is not going to live, and wonders why the staff continues to help her; client may feel guilty about being a burden; nurse helps the client feel that she is not alone and that she is valued and cared for (3) focus of this response is on the nurse; always keep responses client-focused

The LPN/LVN cares for a client with a Sengstaken-Blakemore tube in place to treat bleeding esophageal varices. Which action is most appropriate for management of the care of client with this type of tube? 2. Monitor pressure gauge connected to tubing. 3. Obtain and record blood pressure and pulse.

(2) CORRECT—health care provider sets gauge at pressure adequate to prevent bleeding; pressure gauge needs to be maintained at that pressure to prevent hemorrhage or oozing of blood around tube (3) at risk for hemorrhage; if client begins to regurgitate blood, assess baseline vital signs

The LPN/LVN identifies which of the following as the HIGHEST priority in the initial management of a client diagnosed with a myocardial infarction? 2. Administer pain medication. 3. Assess cardiac rhythm.

(2) CORRECT—pain reduction is the top priority because it reduces the oxygen (O 2) demand on impaired cardiac tissue; primary goal is to prevent further damage to the heart muscle; reducing O 2 demand is the BEST approach (3) assessing cardiac rhythm would be second to relieving chest pain; the rhythm helps the nurse monitor the impending danger to the client; relieving the chest pain reduces the oxygen demand, resulting in reduction of risk to the client; the rhythm warns the nurse of the client's needs

Before insertion of a vaginal radioactive implant, enemas are prescribed for the client. The LPN/LVN understands that the enemas are ordered for which of the following reasons? 2. Decrease the chance of the implant becoming dislodged. 4. Enhance tissue susceptibility to the effects of radiation.

(2) CORRECT—restricting the client's motion will decrease the chance of the implant becoming dislodged; because this includes minimizing use of the bedpan, enemas may be given 4)decreases chance of dislodging implant

he LPN/LVN discovers that a 71-year-old client receiving 40 mEq of potassium chloride (KCl) per day has a serum potassium (K +) of 6.9 mEq/L. While waiting for the health care provider to respond, the LPN/LVN anticipates that which of the following is MOST likely to be ordered? 2. Supplies for enema administration 4. Increase the client's oral fluid intake

(2) CORRECT—sodium polystyrene sulfonate (Kayexalate) via enema is the most common intervention for lowering the serum KCl level; normal level is 3.5-5.0 mEq/L; indications of hyperkalemia include fatigue, muscle weakness, paresthesia, cardiac dysrhythmia (4) secondary intervention if the cause of the hyperkalemia is related to fluid level

The LPN/LVN cares for a client newly diagnosed with paranoid schizophrenia. The client tells the LPN/LVN, "There are really strange people in the corner of my room laughing at me and saying horrible things." Which of the following responses by the LPN/LVN is MOST appropriate? 2. "I don't hear the voices, but this seems to be frightening you." 3. "What are they saying to you?"

(2) CORRECT—the nurse helps the client separate fantasy from reality, and the nurse protects the client's ego by not humiliating him or attempting to talk him out of his hallucination (3) do not reinforce hallucination by validating it; asking client to repeat "horrible" things will serve to cause more discomfort

The LPN/LVN cares for a client diagnosed with cancer of the lung receiving chemotherapy. The LPN/LVN notes that the client's platelet count is 60,000/mm 3. Which of the following actions by the LPN/LVN is MOST appropriate? 2. The LPN/LVN obtains the client's temperature rectally. 4. The LPN/LVN checks the bristles on the client's toothbrush.

(2) avoid trauma to rectal tissue; do not take rectal temperatures or administer enemas (4) CORRECT—client should use a soft-bristled toothbrush, shouldn't floss, and should avoid hard foods; LPN/LVN should assess prior to implementing

The LPN/LVN is assigned to provide care to clients with alternative fecal routes. The LPN/LVN knows that which client requires the greatest amount of teaching? 2. The client with a colostomy of the transverse colon. 4. The client with an ileostomy

(2) contents are intermittent, mushy, and more irritating than at the lower levels (4) CORRECT—contents are almost continuous, liquid, and highly irritating; is more difficult to manage; no predictable bowel pattern will evolve

The LPN/LVN cares for a client after a traditional cholecystectomy. It is MOST important for the LPN/LVN to position the client in which of the following positions? 2. Supine with bed flat. 3. Semi-Fowler's

(2) difficult to breathe and would place tension on the suture line (3) CORRECT—as with any abdominal surgery, semi-Fowler's is optimal for the client, because it will allow increased ability to take the necessary deep breaths that are important to prevent pneumonia after surgery

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? 2. "You need to use a toothbrush with very soft bristles." 3. "Until I can reach your physician, discontinue taking the drug."

(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

When any type of transfusion reaction occurs, the LPN/LVN should take which action first? 2. Slow down the transfusion. 3. Clamp the transfusion line.

(2) immune response needs to be interrupted; decreasing the rate of flow will not eliminate the immune response to the antigen (3) CORRECT— any type of transfusion reaction can be life-threatening; the blood should be stopped immediately if a change in the client's status is noted; the NS IV line will remain open; observe signs and symptoms, obtain vital signs frequently, remain with client

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? 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.

(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

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? 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.

(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

The LPN/LVN cares for clients on the medical/surgical floor. The LPN/LVN determines assignments are appropriate if the nurse assigns the LPN/LVN to which of the following clients 2. A client diagnosed with Raynaud's disease who had a sympathectomy. 4. A client diagnosed with dysrhythmia who had a permanent pacemaker implanted.

(2.) CORRECT — Raynaud's disease is a form of intermittent arteriolar vasoconstriction; sympathectomy interrupts the sympathetic nerves; stable client with an expected outcome (4.) assess client's cardiac output and hemodynamic stability to evaluate the success of the pacemaker

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? 2. "What are the results of the sputum acid-fast bacilli (AFB) smears?" 3. "Did any of your family contract TB?"

(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

The LPN/LVN assists the nurse practitioner in teaching a group of prenatal clients about breastfeeding. Which of the following statements, if made by the LPN/LVN, accurately describes the nutritional needs of a woman during lactation as compared with the nutritional needs of pregnancy? 1. More calories, protein, and calcium are needed during lactation than during pregnancy. 2. More calories but the same amount of protein, calcium, and fluids are needed during lactation.

(2.) CORRECT— more calories but the same amount of protein and calcium are needed during lactation (3.) require more calories

A client with an eye injury wears a patch over the left eye. The LPN/LVN identifies the chief visual disturbance the client will experience while wearing the patch is which disturbance? 2. Difficulty judging the distance of objects. 4. Seeing floating spots in the affected eye.

(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 4. Seeing floating spots in the affected eye.

The LPN/LVN cares for a 78-year-old client admitted to an outpatient unit for repair of a retinal detachment. The LPN/LVN identifies which information as most significant in the client's health history? 2. Corrective surgery for myopia. 3. Diabetes mellitus. 4. Prior cataract surgery.

(2.) common complications include cornea scarring, overcorrection, corneal cloudiness, and others; cataracts are not related to retinal detachment (3.) can cause damage to intraocular arteries, resulting in a retinopathy that causes decreased vision, but is not associated with retinal detachment (4.) CORRECT—45% of clients having cataract surgery are age 75 and over; is one of the most common causes of retinal detachment

The community health LPN/LVN plans visits for the day. Which of the following clients should the LPN/LVN see FIRST? 2. A client complaining of vomiting after chemotherapy. 4. A client with a laryngectomy who is complaining of a greenish-yellow discharge.

(2.) common side effect of chemotherapy; does not require immediate attention (4.) CORRECT— most unstable patient; assess breath sounds and amount, color, and character of drainage

The LPN/LVN identifies which of the following as the correct interval when measuring the frequency of uterine contractions? 2. The beginning of one contraction to the end of the same contraction. 4. The beginning of one contraction to the beginning of the next contraction.

(2.) describes duration of the contraction (4.) CORRECT— the standard measurement for contractions is from the beginning of one contraction to the beginning of the next contraction

The LPN/LVN understands that if acute otitis media is not adequately treated, which complication may develop? 2. Ménière's disease. 3. Mastoiditis.

(2.) disease is associated with fluid balance in the inner ear; not known to be associated with infectious processes (3.) CORRECT—inflammation or infection of the mastoid can occur because of purulent drainage of pus into this area from the ear; caused by untreated or poorly treated otitis media

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 requires administration of digoxin (Lanoxin) and furosemide (Lasix). 4. A client is suddenly confused and sees spiders on the wall.

(2.) medications usually given once per day; no indication client is unstable (4.) CORRECT— sudden confusion and hallucinations indicate delirium, which is a medical emergency

An LPN/LVN implements the nursing care plan designed for a client diagnosed with angina pectoris. It is MOST important for the LPN/LVN to include which of the following instructions? 2. "If you continue to have chest pain after taking 3 nitroglycerin tablets, notify your physician." 4. "It is best for you to avoid ingesting large, heavy meals."

(2.) no response after 3 tablets indicates intervention is not sufficient to meet the need; calling physician is not the BEST intervention to meet the need; physician may not be available, which would result in loss of precious time; should contact EMS immediately (4.) CORRECT— large meals result in shunting of blood to the GI tract, resulting in decreased circulation to the heart and putting the client at risk for cardiac ischemia

After reviewing the laboratory studies of a client suspected of having acute kidney injury, it is most important for the LPN/LVN to notify the supervising nurse because of which finding? 2. Specific gravity of 1.011. 4. Several broad granular casts.

(2.) normal laboratory study (4.) CORRECT— casts are commonly associated with acute kidney injury

To assess an apical pulse on an 8-lb, 4-oz newborn infant, the LPN/LVN should place the stethoscope in which of the following positions? 3. Place the bell of the stethoscope between the fourth and fifth intercostal spaces lateral to the left nipple. 4. Place the bell of the stethoscope between the second and third intercostal spaces on the midsternal line.

(3) CORRECT bell transmits low-pitched sounds like heart and vascular sounds; infants' PMI usually found in the fourth to fifth intercostal space lateral to the left nipple (4)incorrect position

The LPN/LVN understands that bedrest following a myocardial infarction (MI) achieves which outcome best? 3. Decreases the workload on the heart. 4. Allows regeneration of the myocardium

(3) CORRECT—client has altered cardiopulmonary tissue perfusion caused by MI; bedrest during the 24 h will decrease the workload of the heart by reducing myocardial oxygen consumption (4) cellular regeneration does not occur in cardiac tissue; scar tissue forms

Which nursing approach is best for the LPN/LVN to use when caring for a client with a conversion reaction paralysis? 3. Minimize the sick role and secondary gains. 4. Attempt to have the client move periodically.

(3) CORRECT—emphasis for clients with conversion reaction is to minimize the sick role and support the client's strength; it's important to remember client is not consciously attempting to have needs met by others, but is trying to relieve anxiety in an acceptable way; minimizing this instability allows care to be focused on the client's feelings and acceptance of those feelings without encouraging regression and dependence (4) focus on client's feelings; physical damage is not the problem, hence, should not treat the limb as if it is injured or damaged

The LPN/LVN cares for the 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 instruction to the nursing assistive personnel (NAP)? 3. Remove food and water from room. 4. Measure intake and output (I/O).

(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 kidney function; primary focus is on possible preparation of client for impending surgery

The LPN/LVN performs discharge teaching for a client with a right mastectomy. The LPN/LVN determines that teaching is effective if the client makes which of the following statements? 3. "I should empty the drain reservoir twice a day." 4. "I should eat with my left hand until the stitches are removed."

(3) CORRECT—measure and record the amount of drainage; change dressing around the drain as needed (4) can use affected arm for eating or combing hair; do not perform strenuous exercises until after drains are removed

The LPN/LVN understands that which of the following BEST describes the action of glucocorticoids? 3. Converts protein and fat into glucose. 4. Enhances musculoskeletal activity.

(3) CORRECT—reduces the immune response, contributes to the metabolism of all nutrients, including the conversion of protein and fat to glucose (4) calcium is required for muscle contractions

After a motor vehicle accident (MVA), a 17-year-old female client has a permanent colostomy. The client's mother verbalizes to the LPN/LVN that her past relationship with her daughter was difficult, but the relationship has improved since the accident. Because of the improved relationship, the client's mother tells the LPN/LVN that the accident was "a blessing in disguise." The LPN/LVN knows the mother's behavior is MOST representative of which of the following? 3. Denial. 4. Rationalization.

(3) mother is acknowledging accident and colostomy (4) CORRECT—is plausible method of helping one deal with disappointment; helps avoid disapproval; helps soften the impact of loss related to illness

On the evening before his scheduled lung biopsy, a client says to the LPN/LVN, "Do you think I have cancer?" Which of the following responses by the LPN/LVN is MOST appropriate? 3. "Several tests will have to be done to confirm that diagnosis." 4. "You sound worried about what they might find tomorrow."

(3) this response gives information but does not respond to the client's feelings (4) CORRECT—reflects the client's feelings and allows the client to further verbalize

When a client develops a fever on the first postoperative day, the LPN/LVN auscultates rales bilaterally in the lower lobes. The LPN/LVN suspects that which of the following complications of surgery is probably developing? 3. Pulmonary embolism. 4. Atelectasis.

(3)dyspnea and tachypnea, and pleuritic chest pain, are manifestations of pulmonary embolism (4) CORRECT—atelectasis is the most probable cause for the rales; with atelectasis, secretions block the bronchioles and the alveoli collapse, causing hypoventilation

Haemophilus influenzae meningitis 3. Droplet precautions. 4. Contact precautions.

(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

A nursing assistant caring for clients in the long-term care facility collapses minutes after putting on latex gloves. The assistant is successfully resuscitated. After reviewing the medical histories of the staff in the long-term care facility, the LPN/LVN determines which of the following staff members can safely use latex products? 3. The staff member with a history of multiple surgeries. 4. The staff member with a history of GI upset.

(3.) at greater risk for latex allergies (4.) CORRECT— does not cause nurse to be at risk for latex allergies

The LPN/LVN cares for a client in balanced suspension traction. Because the client complains of pain in the affected extremity, the prescribed medication is administered. One hour later the client states, "I don't know why, but the pain isn't getting any better." The LPN/LVN prepares to perform which of the following actions FIRST? 3. Assess the level of client's pain. 4. Perform a neurovascular assessment.

(3.) no reason to validate client is in pain; pain unrelieved by analgesics needs further assessment regarding possible causes (4.) CORRECT—an early sign of acute compartment syndrome is a sudden inability of pain medication to relieve pain

The LPN/LVN notes that the serum sodium level of a client diagnosed with heart failure (HF) is decreased. Which of the following activities should the LPN/LVN perform NEXT? 3. Assess for peripheral edema. 4. Compare current weight to the weight of the day before.

(3.) right-sided heart failure could occur related to decreased pump failure; peripheral edema occurs (4.) CORRECT— rapid weight gain can occur with HF, related to retention of free water resulting in hyponatremia; is best indicator of the etiology of the hyponatremia and takes priority; LPN/LVN should closely monitor disease progression

The LPN/LVN cares for clients in the long-term care facility. The LPN/LVN assists in the admission of a client diagnosed with type 1 diabetes and diabetic neuropathy. The client's daughter states that her mother has a history of depression. The LPN/LVN expects to gather which of the following data? 1. The client's daughter states her mother has decreased attention span and concentration 4. The client states she is in charge of life

1) CORRECT problems with depression occur among people with medical disorders; indications include changes in self-esteem and self-confidence, lack of energy, unkempt appearance, poor appetite (4) depression causes feelings of helplessness and hopelessness

The LPN/LVN notes that a client has a blood calcium level of 13.75 mg/dL. Which of the following actions should the LPN/LVN take FIRST? 1. Assess the quantity, consistency, and color of feces. 2. Assess status of cardiovascular system and central nervous system.

1) constipation is a common sign/symptom of hypercalcemia; is related to the reduced neuromuscular function that results in reduced peristalsis (2) CORRECT—primary functions of calcium include neuromuscular excitability; excessive levels (normal ranges are 9.0 to 10.5 mg/dl) result in suppressed activity of striated and smooth muscles, which could result in cardiac standstill or impaired firing across the cerebral synapses resulting in confusion, decreased memory, and coma

The LPN/LVN implements the care plan initiated by the RN for a client diagnosed with chronic pancreatitis. It is MOST important for the LPN/LVN to instruct the nursing assistant to take which of the following actions? 1. Assess the client's response to analgesia. 4. Weigh the client each morning.

1) is beyond the nursing assistant role; acute pancreatitis brought about by digestion of the organ by enzymes it produces; symptoms include severe abdominal pain, nausea, vomiting, fever, jaundice (4) CORRECT—likely to experience severe weight loss related to decreased metabolism of carbohydrates, proteins, and fats along with diarrhea related to excess fat in the stool

A client with ovarian cancer experiences severe pain. Which of the following principles should the LPN/LVN apply? 1. Caution must be used to prevent narcotic addiction. 4. Pain medication is more effective if given before pain becomes severe

1)primary focus in the management of clients with pain related to terminal illness is narcotic tolerance rather than addiction (4) CORRECT—pain medication given before the peak of severity is more effective in managing the pain

The nursing team consists of two RNs, two LPN/LVNs, and two patient care technicians. The LPN/LVN determines that delegation is appropriate if the LPN/LVN is assigned which of the following? 1. Perform a sterile dressing change. 2. Obtain vital signs.

1.) CORRECT— assist with implementation of care, perform procedures, differentiate normal from abnormal, care for stable patients with predictable outcomes, has knowledge of asepsis and dressing changes, and may administer medications which vary with educational background and state nurse practice acts (2.) appropriate activity for nursing assistants; assist with direct patient care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height and weight, intake and output, housekeeping, transporting stable patients, and stocking supplies

The physician orders streptomycin sulfate 0.4 g IM BID. After reconstituting a 1-g vial of streptomycin sulfate with 3.5 mL of water for injection, the vial contains 250 mg/mL. How many mL per dose should the nurse administer? Type the correct answer in the blank. ___________

1g =1,000mg 250 mg/1ml= 400 mg/x ml x=1.6 ml

vThe LPN/LVN assists the client to determine the appropriate foods for a high-protein diet. The nurse determines teaching is effective if the client chooses which menu? 2. Broiled fish, cream of tomato soup topped with grated cheese, and custard. 4. Turkey sandwich with lettuce and tomato, potato salad, and milk.

2) CORRECT— all foods contain protein; increase protein by adding skim milk to appropriate foods, adding grated cheese to foods, using peanut butter as spread on fruits and vegetables, using yogurt as topping for fruit and cake (4) turkey and milk contain protein, but potato salad does not

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? 2. Place the client on contact precautions. 4. Ask the client if he is experiencing pain or tenderness.

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 (4)primary focus is to control or prevent the spread of the infection

In caring for a client after electroconvulsive therapy (ECT), it is MOST important for the LPN/LVN to take which of the following actions? . 2 Remind the client that memory loss is temporary. 3. Examine the client carefully for fractures.

2) CORRECT—client who has had electroconvulsive therapy will need reassurance that memory loss is temporary; can be frightening and frustrating aspect of the treatment (3) would be appropriate if client predisposed to fractures because of health alterations such as osteoporosis; muscle relaxants, short-acting anesthesia, and barbiturates administered prior to procedure to prevent fractures

The home care LPN/LVN makes a visit to a client reporting symptoms of a urinary tract infection (UTI). The LPN/LVN is ordered to obtain a clean-catch urine specimen. When the nurse arrives at the home, the client states the specimen was collected 2 hours ago and left sitting in the bathroom. Which action by the LPN/LVN is best? 2. Discard the specimen and obtain a new clean-catch specimen. 3. Determine if the client used appropriate technique to cleanse the urethral meatus

2) CORRECT—obtain a freshly voided specimen collected midstream; instruct client to cleanse urethra before voiding to remove secretions or bacteria (3) specimen is contaminated because it was unrefrigerated for more than 1 hour

The LPN/LVN cares for a thin, malnourished, weak client admitted to the unit. The client requires assistance to move about in bed. The LPN/LVN instructs the family about the appropriate technique to use when repositioning the client. The LPN/LVN determines the teaching is effective if which action is observed? 2. The family lowers the head of the client's bed before moving the client up in the bed. 3. The family elevates the knee Gatch when the head of the bed is elevated.

2) CORRECT—reduces pressure on coccyx and other bony prominences supporting the weight of the body (3) reducing circulation to lower limbs results in increased risk of skin breakdown

The LPN/LVN cares for clients in the outpatient clinic. If the LPN/LVN provides care for a young adult, which primary developmental task is expected? 2 Seeking promotion to a high-level position. 3.Making a commitment to a lifetime mate

2) associated more with middle age 3) CORRECT — developing intimate relationships for reproduction is typical of this phase

After several months of isolation, a stage performer agrees to seek treatment for a panic disorder. After the laboratory and diagnostic test results are brought to the unit, the LPN/LVN notifies the health care provider that which information verifies the preliminary diagnosis of an anxiety disorder? 2. The client exhibits reduced serum calcium levels and decreased thalamus function. 4. MRI (magnetic resonance imaging) shows atrophy of the client's frontal lobe and temporal lobe.

2) could indicate kidney injury as well; decreased thalamus function is not symptomatic of panic disorders (4) CORRECT both lobes tend to exhibit decreased size in clients with panic disorders

The LPN/LVN cares for a client immediately after a laryngoscopic examination. It is most important for the LPN/LVN to intervene if which activity is observed?? 2. The client coughs spontaneously. 3. The client drinks from a straw.

2) introducing tube into the throat may cause some irritation; some coughing assures lack of tissue damage during the procedure (3) CORRECT—because local anesthesia is used during the procedure, client should not take fluids orally immediately after the procedure to avoid the possibility of aspiration of fluid into the lungs; should refrain from ingesting fluids until normal swallowing and gag reflex have returned

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? 2 Locate the parents and inform them of the risks. 3.Monitor the child while another person searches for the parents

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

The LPN/LVN identifies which outcome as commonly associated with glaucoma? 2. Unclear images. 4. Decreased peripheral vision.

2.) associated more with cataracts (4.) CORRECT—glaucoma is related to increased pressure within the eyes; untreated glaucoma is one of the most common causes of blindness in the adult

A 5-month-old infant is brought to the clinic by his mother for a well-baby checkup. The LPN/LVN expects to make which of the following observations? 3. The infant puts his feet to his mouth when lying supine. 4. The infant appears afraid of strangers.

3) CORRECT—can roll over from abdomen onto back, able to hold head erect and steady when in a sitting position; able to grasp objects voluntarily, takes objects directly to mouth (4) begins at about 7 months; displays anxiety about strangers at 8 months

Because the spouse has been unemployed for 6 months, a client diagnosed with hypertension is worried they will be unable to pay the rent. Which response by the LPN/LVN is most appropriate? 3. "You're worried that you won't be able to pay the rent." 4. "I will talk with my supervising nurse."

3) CORRECT—reflects feelings of the client; allows the client to focus on what the client said and the client's feelings (4) may need to communicate information to charge nurse; should first allow the client to verbalize

The home care LPN/LVN provides care for a middle-aged client with a history of breast cancer. The client reports drinking milk and walking daily but is afraid of getting shorter. It is most important for the LPN/LVN to advise the client to ask the health care provider about prescribing which medication? 3. Medroxyprogesterone acetate 10 mg PO daily. 4. Risedronate sodium 5 mg PO daily.

3) prescribed for treatment of secondary amenorrhea and abnormal uterine bleeding caused by hormonal balance 4) CORRECT — decreases bone resorption, resulting in the prevention of osteoporosis; instruct to take 30 minutes before eating or taking other medication, remain upright for 30 minutes after taking medication to prevent esophageal irritation

The home health LPN/LVN arrives at the home of a post-myocardial infarction client. The LPN/LVN notes that the client's right leg is swollen and the client is crying because she thinks a swollen leg indicates her heart is failing. Which of the following actions should the LPN/LVN take FIRST? 3. Contact the physician. 4. Instruct the client to elevate the leg.

3.) CORRECT— CHF can be a complication of MI, but bilateral lower-limb edema is usually seen; unilateral edema is commonly associated with obstructed blood vessel(s) on the affected side; this is a serious sign/symptom and warrants immediate attention (4.) etiology is currently unknown; teaching will be appropriate after diagnosis made and treatment prescribed

The LPN/LVN assesses a client with a diagnosis of osteoarthritis. The LPN/LVN is most likely to observe which signs or symptoms? 3. Swollen, reddened, hot, and inflamed joints. 4. Stiffness of the hips, knees, vertebrate, and fingers.

3.) osteoarthritis causes joints to be enlarged but not usually hot and inflamed; inflammation of joints indicates rheumatoid arthritis (4.) CORRECT—osteoarthritis is a "wear and tear" disease characterized by stiffness in the joints, usually in the hips, vertebrae, and fingers

The LPN/LVN makes a home visit to a family that has recently adopted a newborn. The parent is very concerned about the newborn's respiratory rate. Which 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.

4) CORRECT—extreme range; requesting assistance of emergency service is appropriate

The LPN/LVN evaluates the basal body temperature record of a client trying to conceive. Highlight the probable time of ovulation.

Basal body temperature is a method used to determine if client is ovulating; client takes temperature every morning before arising; if client ovulates, there will be a slight drop and then rise in temperature; because of the influence of progesterone, the temperature will be increased during the second half of the cycle.

The LPN/LVN cares for a client after an appendectomy. A full liquid diet is ordered. The LPN/LVN determines the client's breakfast is appropriate if which of the following foods are included? Select all that apply: 1. Apple juice. 2. Pancakes. 3. Banana. 4. Coffee. 5. Thinned oatmeal. 6. Milk.

Breakfast is appropriate" indicates correct information. (1.) CORRECT — full liquid diet includes milk and milk products (pudding, custards), all vegetable juices, all fruit juices, refined or strained cereals, eggs in custard, butter, margarine, and cream (2.) pancakes, biscuits, and muffins are allowed on soft/regular diet (3.) fruit is not allowed on full liquid diet (4.) CORRECT — allowed on clear liquid and full liquid diet (5.) CORRECT — allowed (6.) CORRECT— allowed

he LPN/LVN assists the head nurse in instructing a prenatal client about the warning signs of pregnancy. The LPN/LVN determines that teaching is successful if the client states which of the following? 1. "I should contact the physician if I notice swelling in my face and fingers." 2. "It's not unusual that I might have a little vaginal spotting." 3. "As long as my headaches go away after I take aspirin, I'm okay." 4. "I should report any uterine contractions that I may feel."

Strategy: "Teaching is successful" indicates correct information. (1.) CORRECT— swelling of face or fingers may indicate hypertensive condition; other danger signs include gush of fluid or bleeding from vagina, regular uterine contractions, severe headaches, visual disturbances, abdominal pain, persistent vomiting, fever or chills (2.) any vaginal bleeding should be reported to health care professional (3.) client should avoid taking any medication without consulting the health care provider; aspirin is Pregnancy Risk Category D drug (4.) client should be taught to distinguish Braxton-Hicks contractions from regular uterine contractions; regular uterine contractions should be reported