NCLEX LPN Basic Care and Comfort

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

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.

" Nurse should intervene" indicates incorrect actions. (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 observes a practical nursing student insert a nasogastric tube for enteral feedings. The LPN/LVN should intervene if which of the following is observed? Select all that apply: 1. The practical nursing student encourages the client to swallow while the tube is advanced. 2. The practical nursing student places the plastic nasogastric tube on ice. 3. The practical nursing student performs hand hygiene before beginning the procedure. 4. The practical nursing student puts on gloves before inserting the tube. 5. The practical nursing student advances the tube as the client is coughing. 6. The practical nursing student stands on the side of the bed opposite to the naris used for insertion.

" Should intervene" indicates incorrect actions. (1.) helps facilitate passing the tube (2.) CORRECT— might cause damage to mucous membranes because tube is stiff and inflexible (3.) appropriate action; decreases transmission of microorganisms (4.) appropriate action; decreases transmission of microorganisms (5.) CORRECT— if client coughs or chokes, pull tube back (6.) CORRECT— should stand on the same side of the bed

The LPN/LVN reviews the history obtained from a client diagnosed with degenerative joint disease (DJD) of the right hip. The LPN/LVN identifies which of the following as risk factors for developing degenerative joint disease? Select all that apply: 1. The client had a transurethral resection of the prostate (TURP) 2 years ago. 2. The client worked as a carpet installer for 40 years. 3. The client is a 65-year-old male, height 6 feet, weight 280 lb. 4. The client was diagnosed with diabetes mellitus 10 years ago. 5. The client had a myocardial infarction at age 37.

Determine how each answer relates to degenerative joint disease. (1.) no relationship with prostatic hypertrophy and joint disease (2.) CORRECT— occupation that causes increased mechanical stress to joints, also would be 60+ years old (3.) CORRECT— seen after age 60 years, obesity causes stress to weight-bearing joints (4.) CORRECT— metabolic diseases (diabetes mellitus, Paget's disease) and blood disorders (hemophilia) can cause joint disease (5.) myocardial infarction is caused by coronary artery disease

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.

Determine outcome of each answer. Is it desired? (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

The LPN/LVN cares for a client in Buck's traction. The LPN/LVN should take which of the following actions? Select all that apply: 1. Remove the client's foam boot three times per day to inspect the skin. 2. Turn the client to the unaffected side. 3. Provide back care for the client once per shift. 4. Ask the client to dorsiflex the foot on the affected leg. 5. Offer magazines to the client when the client complains of pain. 6. Elevate the foot of the client's bed.

Determine the outcome of each answer. Is it desired? (1.) CORRECT— important to observe for skin breakdown; a second nurse should support the extremity during the inspection (2.) CORRECT— appropriate if client has a fracture; if no fracture, may turn to either side (3.) back care should be provided every 2 hours to prevent pressure sores (4.) CORRECT— assess function of the peroneal nerve; weakness of dorsiflexion may indicate pressure on the nerve (5.) any complaints of pain should be promptly investigated to rule out nerve pressure (6.) CORRECT— provides countertraction

The LPN/LVN assists in instructing a client diagnosed with a sprained ankle about how to apply a cold application to the ankle. The LPN/LVN should include which of the following instructions? Select all that apply: 1. "Fill a large plastic bag completely full of ice." 2. " Tightly secure the ice bag to your ankle with an ACE wrap." 3. " Apply the ice every two hours for 20 to 30 minutes." 4. " Place a dry cloth over the ice bag." 5. " Observe the area for blanching." 6. " Discontinue using the ice bag if you feel a burning sensation or numbness."

Determine the outcome of each answer. Is it desired? (1.) amount of ice should not be bigger in size than the ankle; large amounts of ice can result in compression of the blood vessels and tissue damage (2.) do not apply tightly to the ankle (3.) CORRECT— decreases swelling and inflammation; do not leave on too long, will cause injury to tissues (4.) dry cloth should be placed between ice pack and skin to prevent tissue damage (5.) CORRECT— do not allow the skin to become too cold (6.) CORRECT— indicates possible skin damage

The LPN/LVN cares for a client with a colostomy. The client is especially concerned about controlling odor and gas. The LPN/LVN asks the client what actions the client has taken to prevent gas and odors. The LPN/LVN should intervene if the client states which of the following? Select all that apply: 1. " I place a breath mint inside the colostomy pouch." 2. " I eat onions, beans, and cucumbers." 3. " I drink cranberry juice and buttermilk." 4. " I eat crackers, toast, and yogurt." 5. " I use a commercially prepared deodorizer inside the pouch." 6. " I chew gum when I get hungry because I skipped a meal."

Determine the outcome of each answer. Is it desired? (1.) appropriate behavior, eliminates odors in the pouch (2.) CORRECT— avoid these foods because they contribute to gas production (3.) appropriate behavior; helps prevent odor; eating parsley and yogurt is also helpful (4.) helps prevent gas (5.) helps eliminate odors (6.) CORRECT— chewing gum, skipping meals, drinking beer, and smoking contribute to the production of flatus

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

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

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

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

The LPN/LVN assists in the management of the care of a client diagnosed with cervical cancer and notes the client appears to have a poor appetite. Which of the following interventions by the LPN/LVN is BEST? 1. Provide high-fat snacks. 2. Provide small, frequent feedings. 3. Provide additional fluid at meals. 4. Provide food only at the client's request.

Strategy: "BEST" indicates discrimination is required to answer the question. (1.) empty calories; clients with cancer may have protein-energy malnutrition that needs to be corrected, as well as having reduced digestive abilities (2.) CORRECT— cardinal rule for increasing total caloric intake for client who has an inadequate intake or who is anorexic is to provide small, frequent feedings (3.) additional fluids can increase feeling of fullness, resulting in decreased solid food intake; could offer high-protein liquids or balanced liquid foods (4.) might assess food likes and dislikes; client request for food is not likely to match nutritional needs

The LPN/LVN assists in performing discharge teaching for a client with a long leg cast to support a fractured left femur. While the cast is in place, the client wants to maintain the muscular strength in the leg. Which of the following responses by the LPN/LVN is BEST? 1. "You'll be taught to perform range of motion exercises." 2. "Your mother will be taught to perform passive range-of-motion exercises." 3. "You'll be taught to perform leg lifts with a two-pound ankle weight." 4. "You'll be instructed how to perform isometric exercises."

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1.) active range of motion increases mobility of the joint; will not affect the muscle (2.) passive exercises performed by another person require no muscle contractions, will not maintain strength (3.) describes active resistive range of motion; will increase muscle tone, but not appropriate for fractured leg covered with a heavy cast (4.) CORRECT—the only safe method of enhancing muscle strength and venous return in a casted extremity is by isometrics, such as quadriceps setting or straight leg raises

The LPN/LVN cares for a fair-skinned client during an acute phase of gouty arthritis. Which of the following BEST describes how the client's affected foot will appear? 1. Pale. 2. Red. 3. Mottled. 4. Cyanotic.

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1.) indicates decreased blood flow (2.) CORRECT—gout is systemic disease caused by inflammation due to urate deposits in the joints; symptoms include redness due to joint inflammation; joint is extremely painful; inspect joint only; too painful to touch (3.) area of discoloration (4.) blue, gray, or purple discoloration of the skin; due to decreased oxygen and increased carbon dioxide

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? 1. "To ensure that an adequate amount skin forms a flap over the residual limb." 2. "To provide for the appropriate amount of circulation needed for healing." 3. "To facilitate the earliest possible prosthetic training." 4. "To prevent an excessive amount of residual limb edema."

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1.) is not limited to adequate amount of skin available to cover the residual limb; provides for circulation to the limb as a whole (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 (4.) while poorly perfused tissue can result in edema, the primary rationale for removing healthy tissue is to assure appropriate healing

The LPN/LVN in the outpatient clinic is measuring the height of a 62-year-old woman. The client expresses surprise that she is 1 1/2 inches shorter. Which of the following statements by the LPN/LVN is BEST? 1. "Having degenerative joint disease of the knees will cause your height to decrease." 2. "Your height has decreased because you have bursitis of the left shoulder." 3. "You are shorter as a result of osteoporosis." 4. "Maybe it is because you were diagnosed with juvenile rheumatoid arthritis."

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1.) osteoarthritis only reduces spaces between joints; if spine bends because of changes, reduced height can occur; osteoporosis results in decreased height more readily than osteoarthritis (2.) bursitis is inflammation of connective tissue sac between muscles, tendons, and bones; caused by repetitive motion and overuse; does not reduce spaces between vertebrae or decrease length of long bones (3.) CORRECT—osteoporosis leads to low bone mass, which results in fractures of spine, wrist, and hip; causes decrease in height (4.) rheumatoid arthritis can decrease height if back bends from changes in the spine; not related to client having the disease since childhood

The LPN/LVN cares for a client receiving the second day of total parenteral nutrition (TPN). The nursing assistant reports to the LPN/LVN that the client is having difficulty breathing. Which of the following actions should the LPN/LVN take FIRST? 1. Lower the head of the bed and decrease the TPN rate. 2. Ask the nursing assistant if dyspnea occurred during ambulation. 3. Assess peripheral pulse proximal to the IV site. 4. Auscultate lungs and review intake/output records.

Strategy: "FIRST" indicates priority. (1) should raise the head of the bed to decrease the work of breathing (2) undiagnosed dyspnea should cause LPN/LVN to go directly to bedside rather than collecting more data from the nursing assistant (3) dyspnea would not be related to impaired circulation in the upper limb; impairment would be more likely to be centrally located (4) CORRECT—respiratory congestion is commonly associated with fluid overload; I/O records would help LPN/LVN determine if overhydration is the problem

The LPN/LVN cares for a client diagnosed with ureterolithiasis. Which of the following actions should the LPN/LVN take FIRST? 1. Administer pain medication. 2. Provide device for straining urine. 3. Instruct client to drink 8 ounces of cranberry juice daily. 4. Place in high Fowler's position.

Strategy: "FIRST" indicates priority. (1.) CORRECT— clients usually experience severe pain; client comfort should take priority (2.) will need to strain urine to determine if stone has been expelled or to determine the contents of the stone (3.) more appropriate for UTI; microorganisms are less likely to grow in acidic solutions (4.) this position will not contribute to client comfort nor will it promote expulsion of the stone

The LPN/LVN helps a client determine how to maintain an adequate intake of protein. The LPN/LVN determines further teaching is required if the client chooses which of the following foods? 1. Peanut butter on whole-wheat bread. 2. Rice and red beans. 3. Orange juice and white toast. 4. Spaghetti and meat sauce.

Strategy: "Further teaching is necessary" indicates incorrect information. (1)both peanut butter and whole-wheat bread contain protein (2)red beans contain some protein (3)CORRECT—juice contains little protein, most of it is in the pulp; bread made from white flour is also limited in its protein content (4)meat sauce contains protein

The LPN/LVN assists in the dietary teaching for a client diagnosed with Graves' disease. The LPN/LVN determines that further teaching is required when the client selects which of the following foods? 1. Brook trout. 2. Apples. 3. Milk. 4. Tea.

Strategy: "Further teaching is required" indicates incorrect information. (1) is acceptable for client's dietary intake; needs a protein source (2) fresh fruit is an acceptable source of natural glucose (3) acceptable for diet; needs foods high in calcium; hyperthyroidism causes osteoporosis (4) CORRECT—tea is a stimulant; since Graves' disease is hyperthyroidism, which results in an excessive basal metabolic rate, do not give the client a food or fluid that would further increase the metabolic rate

The LPN/LVN contributes to the care of several clients who need assistance moving about in bed. The LPN/LVN identifies which of the following clients as being at GREATEST risk for impaired skin integrity? 1. An elderly male client diagnosed in late stage of Alzheimer's disease. 2. An obese female client with a severely fractured right leg in a long leg cast. 3. A post-trauma client with several draining wounds on the lower abdomen. 4. A confused client with hematocrit of 29.1 mg/L, hemoglobin of 10.1 g/dL, and total protein of 4.8 g/dL.

Strategy: "GREATEST risk" indicates that discrimination is required to answer the question. (1) without other impairments, not at risk for of skin impairment (2) may be at risk for skin impairment near edges of cast; will need assistance to turn (3) even with drainage on the skin, would not necessarily be at risk for skin impairment if proper oxygenation, hydration, and nutrition were established (4) CORRECT—since client is confused, malnourished, and at risk for hypoxia, is most at risk for skin impairment; normal hematocrit is 42-50% (men), 40-48% (women); normal hemoglobin is 13-18 g/dL (men), 1-15 g/dL (women); normal total protein is 6.0-8 g/dL

A 60-year-old man is currently employed as a night watchman. He comes for a clinic visit and states he is unable to sleep and fatigues easily. Which of the following is the BEST initial response by the LPN/LVN? 1. "Tell me about your usual sleeping habits." 2. "You probably sleep when you can during your night duty." 3. "This is normal for your age group." 4. "Working the night shift is known to disrupt sleep patterns.

Strategy: "Initial" indicates priority. (1)CORRECT—important to determine client's usual sleep patterns (2)is making an assumption (3)most middle-aged adults do not have trouble sleeping; more common in the older adult (4)provides client with information; primary focus is to discover as much as possible about the client and what may be interfering with his sleep/rest pattern

Strategy: "MOST important" indicates that discrimination is required to answer the question. (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 (2) more commonly associated with liver disease; if ecchymosis occurs in flank or around umbilicus, could indicate internal bleeding (3) occasional hyperglycemia occurs in some clients (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

Strategy: "LPN/LVN should intervene" indicates an incorrect action. (1.) describes tripod position; the basic crutch stance (2.) appropriate gait when bearing weight on only one foot; two-point gait requires partial weight bearing on both feet (3.) appropriate procedure when walking down stairs when unable to bear weight on one leg (4.) CORRECT—because the crutches are to substitute for the affected limb, placing crutches on the affected side allows the client to bear weight on the crutches and the unaffected leg while rising; also prevents accidental weight bearing on the affected leg

The LPN/LVN supervises as a student nurse inserts an indwelling urinary catheter in a female client. The LPN/LVN notes that the catheter was inserted into the client's vagina. Which of the following actions by the LPN/LVN is MOST appropriate? 1. Leave the catheter in place and obtain a new catheterization kit. 2. Explain to the student nurse how costly it is to make this mistake. 3. Remove the catheter and insert a new catheter. 4. Complete an incident report.

Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. (1) CORRECT—the misplaced catheter acts as a landmark; obtain a new catheter for the staff member to insert (2) follow up with staff member after the procedure is completed (3) should leave catheter in place so that mistake will not be repeated (4) incident report is documentation of an abnormal activity that placed client or staff member at risk; insertion of catheter in vagina does neither

The LPN/LVN cares for a client diagnosed with a Colles' fracture of the right hand. The client also has a colostomy. It is MOST appropriate for the LPN/LVN to perform which of the following activities? 1. Strap the colostomy pouch in place as tightly as possible. 2. Change the colostomy pouch q 2-4 hours after meals. 3. Check the seal on the colostomy pouch by having client move about immediately after placement. 4. Empty the colostomy pouch when it is full.

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) because the stoma lacks pain sensation, tissue injury can occur if belt is applied too tightly; Colles' fracture is distal radius fracture (2) CORRECT—stoma should be clean and dry when changing the pouch; select time when risk of bowel evacuation of intestinal contents is least likely to occur (3) client should remain immobile for a short period immediately after application to allow time for the seal to adhere (4) Should empty pouch when it is 1/3 to 1/2 full; prevents constant exposure of stoma to fecal material and weight of full pouch pulling against the seal

A patient recovering from a laparoscopic laser cholecystectomy says to the LPN/LVN, "I hate the thought of eating a low-fat diet for the rest of my life." Which of the following responses by the LPN/LVN is MOST appropriate? 1. "I will ask the supervising nurse to come talk to you." 2. "What do you think is so bad about following a low-fat diet?" 3. "It may not be necessary for you to follow a low-fat diet for that long." 4. "At least you will be alive and not suffering that pain."

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1.) LPN/LVN able to respond to the patient (2.) does not respond directly to the patient's statement (3.) CORRECT— fat restriction is usually lifted as the patient tolerates fat; biliary ducts dilate sufficiently to accommodate bile volume that was held by the gallbladder (4.) nontherapeutic and judgmental

The LPN/LVN assists in caring for a client immediately after the application of a plaster cast. It is MOST appropriate for the LPN/LVN to take which of the following actions? 1. Expose the cast to an ultraviolet lamp for short periods of time. 2. Keep the client's room cool and airy. 3. Rest the casted extremity on a footstool. 4. Cover the cast with a clean cotton sheet.

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1.) air-dry the cast (2.) CORRECT—important to allow the plaster cast to dry from the inside out; warm, dry air would result in rapid drying of the outer surface; ventilation and elevation on pillows provide the best means of meeting this objective (3.) do not rest on hard surfaces; may cause indentation, resulting in pressure areas on client's tissues such as nerves, blood vessels, and skin; if elevation required, place on cloth-covered pillow (4.) do not cover cast while it is drying, can increase drying time and retention of moisture, resulting in decreased cast strength

Which of the following nursing interventions, if performed by the LPN/LVN, is MOST appropriate for a client with rheumatoid arthritis? 1. Provide support of flexed joints with pillows and pads. 2. Position the client on her abdomen several times a day. 3. Massage the inflamed joints with oil and alcohol alternately. 4. Assist with heat application and range-of-motion exercises

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1.) place the joints in functional position; when client lying down, place small pillow under client's head or neck but do not use other pillows to support—will cause flexion (2.) is recommended if client can tolerate position; prevents flexion (3.) apply cold if joints inflamed; heat used to manage pain; make sure that the hot pack is not too heavy or too hot; is limited to reducing the pain experience (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 instructs the nursing assistants to be MOST cautious when ambulating which of the following clients? 1. A client diagnosed with postgastrectomy dumping syndrome. 2. A client who had sigmoidoscopy the previous evening. 3. A client diagnosed with liver disease with ascites. 4. A client 1 day after an appendectomy who has slight fever.

Strategy: "MOST cautious" indicates that discrimination is required to answer the question. (1) CORRECT—food passes from remnant stomach to jejunum too rapidly for the absorption of nutrients; fluid is drawn from the circulation system, causing dizziness, fainting, diaphoresis, and weakness; is at risk for sudden change in status of central nervous system, resulting in risk for falling and damaging the surgical wound (2) may be somewhat dehydrated from bowel preparation the day before; has no surgical wound and is at slight risk for dizziness (3) is at risk for bleeding or bruising should client fall; diagnosis alone does not place at particular risk during ambulation (4) slight fever is expected sign/symptom; small surgical wound does not place at particular risk during ambulatio

The LPN/LVN cares for patients on the medical/surgical inpatient unit. The LPN/LVN plans to prevent the patient with a cerebrovascular accident from experiencing sensory overload. Which of the following plans is MOST effective to prevent sensory overload? 1. Obtain vital signs and assist with A.M. care during the same visit. 2. Obtain vital signs and complete A.M. care 30 minutes later. 3. Complete A.M. care, then transport to physical therapy. 4. Instruct the family to limit visits to 15 minutes.

Strategy: "MOST effective" indicates that discrimination is required to answer the question. (1.) CORRECT—combine activities in one visit to prevent client from becoming overly fatigued; schedule times when client is undisturbed (2.) if nursing staff is in and out of room frequently, contributes to sensory overload and restlessness (3.) clients with brain damage are easily agitated; activity of this volume can agitate client and interfere with recovery (4.) is important to balance the client's need for rest and stimulation; need to be careful that interventions do not lead to sensory deprivation

The LPN/LVN cares for clients on the medical/surgical unit The LPN/LVN understands that which of the following environmental factors is MOST helpful to maintaining independence for a client who is legally blind? 1. A radio placed on the client's bedside table. 2. A call light that is easy to reach. 3. The furniture in the client's room is consistently arranged. 4. A room with a private bathroom.

Strategy: "MOST helpful" indicates that discrimination is required to answer the question. (1.) helps the client stay in touch with the outside world, but contributes little to helping the client gain independence in the current environment (2.) is helpful if client needs to call for help, but focus is on client learning to manage independently (3.) CORRECT—to function independently, a severely visually impaired person needs to know where things are; the bedside table and night stand, for example, should always be kept in the same place so that the client can easily locate belongings and avoid injury (4.) may feel more comfortable with a private bath, but if the LPN/LVN is focusing on independence, a predictable and a stable environment takes priority

During the acute phase of gout, which of the following interventions by the LPN/LVN is MOST helpful to decrease pain during ambulation? 1. Perform passive range-of-motion exercises. 2. Encourage partial weight bearing. 3. Immobilize the extremity. 4. Restrict ambulation to inside the room.

Strategy: "MOST helpful" indicates that discrimination may be required to answer the question. (1.) need to determine methods to reduce discomfort during ambulation; passive exercises will maintain circulation and range of motion but will not help client "figure out" what works best during ambulation (2.) CORRECT—encouraging partial weight bearing, perhaps with a walker; a walker would relieve weight, pressure, and stress on the affected leg (3.) would not help client determine how to reduce pain during ambulation (4.) restricting site of ambulation would help client decide BEST method for relieving pain during ambulation; might consider ambulating when medication reaches the peak of its effectiveness

The LPN/LVN cares for a client diagnosed with AIDS complaining of diarrhea. It is MOST important for the LPN/LVN to take which of the following actions? 1. Decrease roughage in the client's diet. 2. Encourage the client to eat three meals per day. 3. Instruct the client to increase intake of dairy products. 4. Inform the client to decrease fluid intake.

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) CORRECT—avoid foods that stimulate intestinal motility, such as vegetables and fruits; fatty, spicy, and sweet foods; alcohol; and caffeine (2) small, frequent meals are better tolerated (3) lactose intolerance can contribute to diarrhea (4) drink lots of fluids, especially between meals

An older client with benign prostatic hypertrophy had a transurethral prostatectomy yesterday. It is MOST important for the LPN/LVN to instruct the nursing assistants to perform which of the following activities? 1. Subtract irrigation fluid from total volume. 2. Turn, cough, and deep breathe client every 2 hours. 3. Assist the client with personal care. 4. Measure vital signs every 4 hours and report changes.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1.) CORRECT— because catheter can become obstructed or flow too rapidly and cause damage to the bladder; need to know is flowing at appropriate rate; also need to determine urinary output (2.) to maintain respiratory function, is part of post-operative care for any client (3.) although does not have a skin wound, will have pain and exhibit weakness and drowsiness associated with administration of general anesthesia and narcotics; is not directly related to this procedure (4.) is at risk for circulatory changes; should be monitored; less likely to occur than occlusion of the urinary catheter

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. 3. Report imbalance of intake and output. 4. Protect skin from injury.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (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 (3.) increased cortisol levels can result in fluid retention that is not life-threatening; risks are long term (4.) long-term outcome of high serum cortisol levels can result in thinning of the skin; needs to protect from injury; injury to the skin does not affect health status as significantly as infectious processes

The LPN/LVN in the long-term care facility cares for a client who is on bedrest. It is MOST important for the LPN/LVN to perform which of the following? 1. Plan midmorning and midafternoon naps for the client. 2. Encourage an increase in client's daily fluid intake. 3. Place a doughnut-shaped cushion beneath the client's buttocks. 4. Observe for sensory deprivation.

Strategy: "MOST important" indicates priority. (1) important that client maintain a regular sleep/wake schedule; extra naps may cause a problem in the client's regular diurnal schedule (2) CORRECT—urinary stasis often occurs in immobile clients, which results in increased risk of cystitis; adequate fluid intake can prevent or reduce cystitis (3) increased compression of tissues results in increased ischemia, resulting in increased risk of decubiti (4) important, but priority is to prevent physical problems

The LPN/LVN assists the campus nurse at the local university. A student who lives in a campus apartment is diagnosed with hepatitis A. It is MOST important for the LPN/LVN to take which of the following actions? 1. Arrange for delivery to the student of six small meals per day. 2. Arrange to have the student's homework delivered to a specific professor. 3. Arrange to have groceries delivered to the apartment on weekly basis. 4. Arrange for pickup and delivery of student's laundry.

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1) CORRECT—anorexia and malaise are common problems; provides for prepared meals; more likely to eat several small meals rather than three large meals; hepatitis A is transmitted through the fecal-oral route (2) health maintenance takes priority; will feel more like completing homework if nutritional needs are met (3) because malaise, fatigue, and anorexia are common problems, is not likely to prepare meals (4) laundry needs should be addressed; if nutritional needs are met, will be more apt to take care of laundry needs

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. 2. Inform the client to report excessive bruising. 3. Perform finger-stick blood sugar. 4. Weigh the client each morning.

Strategy: "MOST important" indicates that discrimination is required to answer the question. (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 (2) more commonly associated with liver disease; if ecchymosis occurs in flank or around umbilicus, could indicate internal bleeding (3) occasional hyperglycemia occurs in some clients (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

The LPN/LVN cares for a woman newly diagnosed with type 1 diabetes. The client shares with the LPN/LVN that even though she ate "all the time," she lost 30 pounds in the previous 3 months. The LPN/LVN notes that the client is quite slender. It is MOST important for the LPN/LVN to include which of the following during client teaching? 1. "Because you have diabetes, your dietary requirements will be difficult to meet." 2. "Your caloric intake will be increased temporarily." 3. "Your daily activities need to be changed to match the times you administer the insulin." 4. "You should vary the times that you eat your bedtime snack."

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1) proper planning around food preferences can significantly decrease feelings of deprivation (2) CORRECT—significant weight loss can occur during undiagnosed diabetes mellitus; slender clients will need to increase caloric intake temporarily until the desired weight gain is attained (3) current insulin management guidelines recommend adapting the insulin schedule to meet the client's needs (4) consistency is the primary guideline for management of diabetes mellitus; should eat foods as much as possible at the same time

The LPN/LVN supervises clients in the adult day-care facility. One of the clients states that she is having difficulty with stress incontinence. The client is a 78-year-old female who is 5 feet, 2 inches tall, weighs 180 pounds, and has a history of four live births. It is MOST important for the LPN/LVN to make which of the following suggestions to the client? 1. "Start wearing adult diapers during strenuous activity." 2. "Weight reduction will help decrease stress incontinence." 3. "Drink less water a few hours before bedtime." 4. "You will have to get used to this since you are 78 years old."

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1) stress incontinence is unpredictable; would need to wear them all the time; alternatives to protective clothing exist (2) CORRECT—increased abdominal pressure caused by obesity contributes to stress incontinence; instruct client how to perform pelvic muscle exercises (3) should drink adequate amounts of fluids but avoid foods with caffeine and alcohol because they have a diuretic effect; can accidentally expel urine regardless of the volume of fluid (4) while may be more prominent in this population, there are remedies that can reduce or eliminate the problem

The LPN/LVN cares for an older man admitted to the hospital for treatment of a fractured femur. The LPN/LVN notes the client is very hard of hearing. It is MOST important for the nursing staff to provide which of the following? 1. Intellectual challenges. 2. Quiet environment. 3. Private visits with his wife. 4. Social interaction.

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1.) providing resources to help maintain or stimulate mental activities can help client but more important to provide social interaction (2.) may need quiet environment at times, but primary problems are isolation and loneliness (3.) needs private time with his wife but she cannot meet all of his interaction needs; she will need to get away from the hospital environment to meet her own needs (4.) CORRECT—in late adulthood, social interaction is important to maintain the client's self-esteem; the plan should provide for social interaction

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. 3. Frequent episodes of upper abdominal guarding. 4. Increased alanine aminotransferase (ALT).

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (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 (3) could indicate ruptured gallbladder; clients with inflamed gallbladders are not candidates for solubilizing drugs (4) more indicative of liver disease; disease or injury results in release of the enzyme into the bloodstream

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 of the following positions? 1. Abducted with toes pointing upward. 2. Elevated on two pillows with knees flexed. 3. Elevated on several pillows with the ankle abducted. 4. Adducted with ankle joint hyperextended.

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (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 (2.) should avoid flexing hip; might dislocate prosthesis (3.) extreme flexion at the hip joints could dislodge prosthesis (4.) needs to be aligned with the body; adduction applies pressure on the hip joint; can dislocate prosthesis

The LPN/LVN assists in the care of an elderly client 8 days after an open reduction and internal fixation of the right hip. It is MOST important for the LPN/LVN to report which of the following client behaviors to the charge nurse? 1. The client ate half of the food on the breakfast tray. 2. The client is not wearing elastic stockings. 3. The client transfers from the bed to bedside commode with assistance. 4. The client requires pain medication three times per day.

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1.) poor appetites are common in the elderly even during healthy periods; is relevant to recovery from surgery but does not place client at risk for a life-threatening alteration (2.) CORRECT—DVT is the most common complication associated with orthopedic surgery as well being a risk of immobility; elderly are more prone because of decreased muscle tone; should wear elastic stockings or use sequential compression device (3.) appropriate behavior; getting client up will help prevent atelectasis along with other complications of immobility (4.) pain continues several days after surgery as client begins to ambulate and bear weight on the healing tissue

The 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? 1. Seizure precautions. 2. Supplies for enema administration. 3. Supplies for venipuncture initiation. 4. Increase the client's oral fluid intake.

Strategy: "MOST likely" indicates that discrimination is required to answer the question. (1) hyperkalemia can impair the central nervous system; health care provider is most likely to order activity to lower the K+ level (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 (3) insulin can be administered for hyperkalemia via IV infusion or IVP; is not most commonly used mechanism (4) secondary intervention if the cause of the hyperkalemia is related to fluid level

The LPN/LVN in the outpatient clinic assesses a client diagnosed with trigeminal neuralgia. The LPN/LVN should intervene if the client makes which of the following statements? 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 wife'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 assists in the evaluation of care given to a client after a left below-the-knee amputation. Which of the following nursing interventions is MOST relevant for this client? 1. Place a tourniquet on the client's bedside table. 2. Encourage the client to lie on his stomach several times per day. 3. The LPN/LVN uses a transfer belt when client transfers from bed to chair. 4. Ask the client to sit in a chair frequently for short periods of time.

Strategy: "MOST relevant" indicates priority. (1.) CORRECT—tourniquet is placed in plain sight on the client's bedside table; hemorrhage due to loosened suture is a threatening problem; if hemorrhage occurs, apply tourniquet and notify physician immediately (2.) appropriate action; will prevent flexion contractures of the hip and promotes ability to ambulate with a prosthesis attached (3.) appropriate to stabilize client with transfer belt; can reduce the risk of falling; not as significant as risk of hemorrhage (4.) to prevent flexion contractures of the hip, client should not sit for long periods of time; mobility contributes to recovery from surgery as well as increasing or maintaining muscular strength needed for rehabilitation

The LPN/LVN assists in instructing a client with a history of repeated urinary tract infections. Which of the following statements, if made by the client to the LPN/LVN, indicates the need for further teaching? 1. "I can go all day without emptying my bladder." 2. "I drink two liters of fluid every day." 3. "I do not use bubble bath." 4. "I drink cranberry juice each day."

Strategy: "Need for further teaching" indicates incorrect information. (1) CORRECT—should empty the bladder every 4 hours even if there is no urge; urinary stasis increases the risk of microorganism growth (2) adequate fluid intake reduces the risk of cystitis. (3) bubble bath, nylon underwear, and scented toilet tissue are irritating; clients using bubble bath tend to develop cystitis (4) makes urine acidic, which decreases incidence of infection

A home care LPN/LVN monitors a client diagnosed with Alzheimer's disease who is receiving tube feedings. The LPN/LVN observes the client's spouse administer a tube feeding to the client. The LPN/LVN should intervene if which of the following is observed? 1. The client's spouse changes the bag every 24 hours. 2. The client's spouse administers feeding directly from the refrigerator. 3. The client's spouse checks for residual immediately before each feeding. 4. The client's spouse stops the feeding if client becomes restless.

Strategy: "Nurse should intervene" indicates an incorrect behavior. (1) bacterial growth will be at unsafe level if feeding is left at room temperature longer than 24 hours (2) CORRECT—should be at room temperature; instilling cold solution directly into the gastric vault will cause cramping; normally, solution is warmed by the oral cavity and esophagus before reaching the gastric mucosa (3) if residual is the same as infused amount, the volume is too great, infusion is too rapid, or peristalsis is inadequate; normal residual is 90 cc; greater than this amount needs to be reported to health care provider (4) client with Alzheimer's may not be able to communicate discomfort

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? 1. "I really like a lot of cream on my oatmeal." 2. "We eat a lot of broiled fish and chicken." 3. "I can't wait to eat the chocolates my children gave me." 4. "My favorite dish is broccoli with cheese sauce."

Strategy: "Report a positive outcome" indicates correct information. (1) because impaired bile salts flow is probable, should avoid foods high in fat; cream is high in fat and may precipitate pain, nausea, and vomiting (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 (4) avoid gas-forming vegetables such as cabbage, onions, broccoli, cucumbers; also avoid high-fat dairy products such as whole milk, cream, cheese, and ice cream

The home care LPN/LVN makes a visit to a client diagnosed with degenerative joint disease. The LPN/LVN asks the client's wife if she has noticed the client having any problems. The LPN/LVN should further assess if the client's wife states which of the following? 1. "I can tell that my husband has been worrying because he is wringing his hands." 2. "Last night my husband carried a big bowl of vegetables to the table using both hands." 3. "My husband bends from the knees when he picks the papers up from the floor." 4. "My husband only uses a small pillow under his head when he sleeps at night."

Strategy: "Should further assess" indicates a potential problem. (1.) CORRECT—to protect joints, the client should avoid a twisting or wringing motion of the hands (2.) using both hands to hold or carry objects protects the joints (3.) appropriate behavior; do not bend from the waist (4.) appropriate behavior; using a large pillow or multiple pillows can cause flexion contracture of the neck, which will cause increased discomfort

The LPN/LVN assists in the care for a client after a total hip replacement due to degenerative joint disease (DJD). The LPN/LVN should intervene if which of the following is observed? 1. The client uses an incentive spirometer every 2 hours. 2. The client is positioned with a pillow between the legs. 3. The client is positioned with heels on the bed and toes pointed upward. 4. The client moves slowly when getting out of bed.

Strategy: "Should intervene" indicates a complication. (1.) prevents atelectasis and pneumonia (2.) prevents dislocation of the prosthesis (3.) CORRECT—elderly are prone to pressure sores; keep heels off bed to prevent pressure sores; pressure sores occur when soft tissue is trapped between a hard surface and a bony prominence (4.) reduces safety risks associated with orthostatic hypotension

The physician orders a clear liquid diet for a client diagnosed with diverticulitis. The LPN/LVN instructs the family about the appropriate foods. The LPN/LVN should intervene if the client's family makes which of the following statements? 1. "Grandpa can have his daily glass of prune juice." 2. "My husband really likes apple juice." 3. "My dad drinks cranberry juice in the evening." 4. "Grandpa can eat a cherry popsicle with me."

Strategy: "Should intervene" indicates incorrect information. (1) CORRECT—clear liquid diet allows clear liquids (liquids that the LPN/LVN can see through or foods that are fluid at room temperature); prune juice allowed on a full liquid diet; diverticulitis is infection and inflammation of the diverticulum; signs include irregular bowel function with episodes of diarrhea, crampy pain in left lower quadrant, and low-grade fever (2) apple, cranberry, and grape juices that are strained, as well as gelatin, are allowed; clear liquids require minimal digestion and there is little residue (3) carbonated beverages and bouillon allowed; clear liquid diet doesn't contain adequate amounts of calories or nutrients (4) popsicles (flavored and colored water frozen on a stick), tea, regular and decaf coffee allowed

The LPN/LVN assists teaching a client how to properly increase calories in the diet. The LPN/LVN determines the teaching is effective if the client makes which of the following statements? 1. "I will broil all my meats." 2. "I will eat bread at all my meals." 3. "I will snack frequently on nuts and dried fruits." 4. "I only use low-fat salad dressings."

Strategy: "Teaching is effective" indicates correct information. (1) broiling does not add calories (2) bread adds carbohydrates; fat adds calories (3) CORRECT—increased frequency of eating, as well as eating foods high in fat and carbohydrates, adds calories; calories should add healthy nutrients (4) does not add calories

The LPN/LVN assists in the dietary teaching for a client diagnosed with a myocardial infarction. The LPN/LVN determines teaching is effective if the client selects which of the following menus? 1. Ham and cheese sandwich, milk, fresh apple. 2. Sliced turkey, green beans, fresh pear. 3. Broiled fish, creamed spinach, custard. 4. Broiled chicken, green beans, ice cream.

Strategy: "Teaching is effective" indicates correct information. (1) client should avoid saturated fats and foods high in cholesterol; avoid intake of salty foods; diet should be rich in fruits, vegetables, grains, and fish, as well as high-fiber; ham is salty, and cheese is high in fat (2) CORRECT—sliced turkey, green beans, and pear are all low in cholesterol and low in salt; other meals are high in cholesterol and salt (3) broiled fish is good, but creamed spinach is high in fat, as is custard (made with milk and eggs) (4) boiled chicken and green beans are acceptable foods; ice cream high in fat and high in sugar

The LPN/LVN helps a client diagnosed with anemia learn why folic acid should be included in the daily dietary intake. The LPN/LVN determines teaching is effective if the client makes which of the following statements? 1. "Folic acid contributes to the maintenance of the bone marrow function." 2. "Without folic acid, the RBCs are weak and die before reaching the bloodstream." 3. "Folic acid contributes to development of red blood cells only." 4. "Clients with alcoholism should decrease the folic acid intake."

Strategy: "Teaching is effective" indicates correct information. (1) folic acid contributes to DNA synthesis but does not maintain the bone marrow; anemia is a decrease in the number of erythrocytes or a reduction in hemoglobin (2) CORRECT—RBCs produced with inadequate folic acid intake are large with a shorten lifespan; an inadequate number of misshapen RBCs reach the bloodstream (3) contributes to WBC, RBC, and platelet development (4) alcoholism increases the folic acid requirement; alcoholic clients often have an inadequate dietary intake

A client is scheduled for bowel surgery, and the physician orders a low-residue diet as a part of the bowel preparation. The LPN/LVN teaches the client about foods allowed on a low-residue diet. The LPN/LVN determines teaching is effective if the client chooses which of the following menus? 1. Bouillon, grilled cheese sandwich, and grapes. 2. Corned beef, buttered peas, and custard. 3. Roast lamb, buttered rice, and sponge cake. 4. Strained cream of asparagus soup, bacon and tomato sandwich, and a sugar cookie.

Strategy: "Teaching is effective" indicates correct information. (1) grapes are not allowed on low-residue diet because of the skin on grapes (2) tender meats are allowed; corned beef is not a tender cut of meat; because of the skin on the peas, they are not permitted (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 (4) soup is permitted; because of the skin on tomatoes and the pulp, they are not allowed; the lean meat contained in bacon would be considered fibrous

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 that teaching is effective if which of the following is observed? 1. The family grasps the client under the shoulders and slides the client to the head of the bed. 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. 4. The family thoroughly massages the reddened areas noted on the client's buttocks.

Strategy: "Teaching is effective" indicates correct information. (1) sliding across bed causes shearing, which can separate skin from underlying tissue (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 (4) do not massage reddened areas; reddened areas could indicate damage to deep tissues; best approach is to provide pressure release

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

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

During a home appointment, an older adult client informs the LPN/LVN that she is having problems with chronic constipation. The LPN/LVN offers the client instructions about how to prevent constipation. The LPN/LVN determines that teaching is successful if the client states which of the following? 1. "I will take a laxative daily at bedtime." 2. "I should take a small-volume enema to prevent straining." 3. "I will drink more fluids and take frequent short walks." 4. "I will keep a written log of when my bowels move and a description of the stools."

Strategy: "Teaching is successful" indicates correct information. (1) use of laxatives can become addictive; more natural interventions are appropriate; prevention is the primary concept (2) like laxatives, enemas can become addictive; prevention is the primary concept; could be utilized to relieve current discomfort but should not be utilized on a regular basis (3) CORRECT—increased fluid increases the volume of colonic contents, resulting in softer contents and more regular peristalsis; increased activity also increases peristalsis (4) will contribute little to resolving the problem

The LPN/LVN cares for a client with a newly constructed ileostomy. The ostomy nurse visits the client to provide instructions about caring for the ileostomy. Which of the following statements, if made by the client to the LPN/LVN, would cause the LPN/LVN to notify the ostomy nurse? 1. "The ostomy bag may need to be emptied four or five times daily." 2. "I know that if a leak occurs, I need to change the drainage bag immediately." 3. "I am looking forward to living without having this bag attached to me." 4. "I will notify the LPN/LVN immediately if my skin gets irritated."

Strategy: "Would cause the LPN/LVN to notify the ostomy nurse" indicates incorrect information. (1) because flow occurs unpredictably throughout the day and the contents can be irritating to the tissue, will require frequent emptying (2) because can be irritating to tissue, need to change immediately (3) CORRECT—unlike a colostomy, drainage from an ileostomy is liquid and flows intermittently throughout the day for the rest of client's life; will need to wear bag all the time (4) because cannot move bag to another site, any skin irritation needs to be addressed immediately; skin breakdown is difficult to heal

The LPN/LVN instructs a client diagnosed with eczema about the appropriate diet. The LPN/LVN should intervene if the client states which of the following? 1. "Fish, nuts, and chocolate are my favorite foods." 2. "I eat strawberries, tomato, and apples every day." 3. "I have milk, wheat cereal, and scrambled egg whites for breakfast." 4. "I include soybeans, orange juice, and egg yolks in my diet."

Strategy: All parts of the answer have to be correct. (1)eczema is an inflammatory rash caused by allergic immune response; nuts commonly cause anaphylactic reaction; other foods do not (2)berries can cause anaphylactic reaction; the other foods are known to do so (3)CORRECT—are all common allergens associated with eczema (4)some legumes can cause an anaphylactic reaction; eggs are a common allergen

Which of the following nursing interventions by the LPN/LVN is MOST effective in promoting adequate nutrition for clients undergoing radiation and chemotherapy? 1. Include client's choices in meal and snack selection. 2. Ensure that meals are served hot. 3. Offer salty snacks every 2 hours. 4. Serve additional portions of food at mealtime.

Strategy: Determine the outcome of each answer. Is it desired? (1) CORRECT—clients should be included in meal and snack selections as much as possible; assist clients to identify foods that are appealing; offer small, frequent feedings of nutrient-dense food (2) cold foods or foods served at room temperature are better tolerated than hot foods (3) do not offer client foods with empty calories; foods should be attractive and nutrient-dense (4) allow client to choose foods; appetite may decrease throughout day, so offer high-protein, high-calorie, nutrient-dense foods at breakfast

The LPN/LVN cares for a homebound client diagnosed with thrombophlebitis. The physician orders the client to be on bedrest. It is MOST appropriate for the nurse to perform which of the following activities? 1. Raise or lower head of bed q 2 hours. 2. Place client in the prone or supine position. 3. Encourage client to take a bowel softener of choice daily at bedtime. 4. Omit client's oral calcium supplements.

Strategy: Determine the outcome of each answer. Is it desired? (1) CORRECT—maintains baroceptors to prevent decreased cerebral perfusion; if procedure is omitted, client is likely to faint when placed in a standing position (2) best position is on side to prevent distribution of weight over large bony prominences (3) more natural interventions recommended, such as adequate fluid and food fibers (4) bone demineralization likely to occur without normal weight-bearing; needs to continue taking calcium supplements along with adequate fluid intake

The home care LPN/LVN visits a client with a diagnosis of ulcerative colitis. The client states that she has perineal irritation due to frequent stools. Which of the following suggestions by the LPN/LVN is BEST? 1. Apply a heat lamp to the perineal area three times per day. 2. Use protective plastic bed pads. 3. Clean the perineal area with soap and water after each bowel movement. 4. Increase roughage in the diet to prevent the frequent stools.

Strategy: Determine the outcome of each answer. Is it desired? (1) increases blood flow, which results in increased irritation (2) increases irritation by keeping moisture close to body; promote healing by keeping site clean and dry (3) CORRECT— keeps the skin free of stool; exposure of irritated area to urine and stool increases risk of irritation (4) low-residue diet recommended; increased roughage increases peristalsis, which can further aggravate the condition

The LPN/LVN cares for a client after a lumbar diskectomy. To promote maximum mobility with the highest comfort level, it is MOST important for the LPN/LVN to give the client which of the following instructions? 1. "Plan for extended rest periods after performing prescribed activities." 2. "Sleep on a firm mattress with your body lying flat." 3. "Do not sit, stand, or walk for long periods of time." 4. "Rest in a prone position with your head on a pillow when you feel uncomfortable."

Strategy: Determine the outcome of each answer. Is it desired? (1) long rest periods tend to result in deconditioning (2) lying with head and thorax raised to 30-degree angle with pillows is recommended; prevents pressure on lower back muscles (3) CORRECT—balanced activity prevents overuse resulting in injury or underuse resulting in deterioration of function (4) prone position emphasizes lordosis, especially if head is resting on pillow; back muscles are in a constant state of contraction

The LPN/LVN teaches family members how to help a client get out of the hospital bed. It is MOST important for the LPN/LVN to state which of the following? 1. "Use your lower-back muscles when lifting the client." 2. "Place the bed at a height comfortable for the client." 3. "Lift the client using a rocking motion." 4. "Flex your knees and use your leg muscles to lift the client."

Strategy: Determine the outcome of each answer. Is it desired? (1) lower-back muscles are small and are not designed for heavy lifting (2) place bed at height comfortable for individuals lifting the client; a stool can be provided for the client if needed (3) the use of smooth, regular movements is recommended (4) CORRECT—utilizes largest muscles for heavy lifting; prevents back injuries

After being dialyzed, a client is admitted to the hospital with a diagnosis of acute renal failure (ARF). The LPN/LVN is MOST likely to perform which of the following nursing actions? 1. Teach client the signs/symptoms of hyperkalemia. 2. Teach the client about the etiologies of the disease. 3. Encourage adequate fluid intake. 4. Teach to report signs/symptoms of anemia.

Strategy: Determine the outcome of each answer. Is it desired? (1.) CORRECT— in acute renal failure the kidneys cannot excrete potassium; slight fluctuations can be life-threatening (2.) altering conditions that caused the changes will not contribute to management of the current status; will be part of the teaching process, but will not be as life saving as teaching client about current, potentially life-threatening changes (3.) likely to be restricted (4.) because of the decreased production of erythropoietin, anemia is likely to occur in ARF; signs/symptoms are generalized, such as fatigue; similar signs/symptoms occur after dialysis; would need regular laboratory studies to monitor anemia

When providing care to a client with a newly applied long leg plaster cast, the LPN/LVN should take which of the following actions? 1. Set up a fan to blow on the cast, and turn the client frequently. 2. Rest the casted leg on the mattress and avoid handling cast until it has dried. 3. Elevate the leg on pillows and leave the cast open to air. 4. Cover the cast lightly with a sheet and remove it frequently.

Strategy: Determine the outcome of each answer. Is it desired? (1.) client should be turned q 1 to 2 hours; cast should be exposed to air; rapid drying of cast traps moisture inside the cast, resulting in reduced strength (2.) resting cast on a firm mattress is appropriate, but client should be turned every 1 to 2 hours to ensure that cast dries on all sides (3.) CORRECT—elevation of the extremity will prevent edema; elevation on pillows will prevent the cast from having contact with a hard surface that might cause pressure; leaving the cast open to air will facilitate drying (4.) covering the cast will delay drying time

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? 1. Aspirate residual stomach contents. 2. Clamp tubing when feeding is complete. 3. Irrigate with 30 to 50 mL when feeding is complete. 4. Elevate the head of the bed before initiating the procedure.

Strategy: Focus on the question. (1) assesses movement of feeding through the gastrointestinal tract; more than 90 mL in the stomach indicates delayed gastric emptying (2) prevents air from entering the stomach between feedings (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

After a sustained elevated temperature, a client develops a fecal impaction. The LPN manually removes the fecal impaction. During the procedure, it is MOST important for the LPN/LVN to instruct the nursing assistant to perform which of the following activities? 1. Procure extra packets of lubricant. 2. Prepare to administer a low-volume enema. 3. Hold the client's hand. 4. Measure the client's pulse.

Strategy: Gather data before implementing. (1) monitoring the status of the client during the procedure takes priority (2) depending on the situation, some clients may need low-volume enema to soften feces that is inaccessible; does not protect client from possible injurious outcomes associated with the digital manipulation of the rectum during this procedure (3) procedure can be extremely uncomfortable; many clients require some type of comforting (4) CORRECT—digital manipulation can result in vagal stimulation, which can result in hypotension and bradycardia; monitoring during the procedure can alert the LPN/LVN to the problem and procedure will stop

The LPN/LVN cares for a client with a nasogastric (NG) tube attached to low suction. The previous shift reports that the client had a high volume output the last 4 hours of the shift. It is MOST important for the LPN/LVN to instruct the nursing assistant to perform which of the following activities? 1. Apply oil-based lubricant to nostril. 2. Perform minimal morning hygiene activities. 3. Obtain vital signs q 1 hour. 4. Assist the client with ambulation.

Strategy: Gather data before implementing. (1) water-based lubricant is recommended; oil-based can reduce tape adherence; oil-based molecules can be inhaled and result in an aseptic pneumonia (2) dehydration can result in fatigue; minimizing activities until problem is resolved could reduce degree of fatigue; reducing fatigue is not as threatening as the risk to vital organs (3) CORRECT—data provide a more precise estimate of client status; observe for indications of fluid volume deficit (4) dizziness can accompany dehydration, especially if occurs rapidly; will need assistance with ambulation; is more important to determine client status; changes in vital signs may indicate ambulation should be delayed

The LPN/LVN assists in the care of a client diagnosed with esophageal diverticula. The LPN/LPN determines that care of this client is effective if which of the following is observed? 1. The client's stool specimen is negative for occult blood. 2. The client gained 4 pounds during the previous 30 days. 3. The client has decreased signs/symptoms of inflammation/infection. 4. The client has decreased episodes of pyrosis.

Strategy: Look for a positive outcome. (1) more commonly associated with PUD (peptic ulcer disease); indications include pain 2-3 hours after meals; food intake relieves the pain (2) CORRECT—primary problem is dysphagia, resulting in inadequate food intake; primary goal is to increase nutritional status; diverticula is saclike outpouching of the lining of the GI tract that goes through the muscle layer (3) can become inflamed if food is trapped in the sac; dysphagia is a problem clients commonly experience (4) heartburn; more commonly associated with gastric-esophageal reflux disease (GERD)

The 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 of the following menus? 1. Chef salad, crackers, and iced tea. 2. Broiled fish, cream of tomato soup topped with grated cheese, and custard. 3. Peanut butter and jelly sandwich, chips, and fruit drink. 4. Turkey sandwich with lettuce and tomato, potato salad, and milk.

Strategy: Recall foods that are high in protein. (1) chef salad contains pieces of ham and cheese, which have protein; crackers and iced tea do not contain protein; majority of food do not contain protein (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 (3) peanut butter contains protein, but the other foods do not (4) turkey and milk contain protein, but potato salad does not

A client diagnosed with acute renal failure (ARF) asks the LPN/LVN why the dietary recommendations include high carbohydrate content with low protein content. Which of the following responses by the LPN/LVN is BEST? 1. "Carbohydrates are utilized for energy first." 2. "A high-carbohydrate, low-protein diet prevents the development of hypertension." 3. "A high-carbohydrate, low-protein diet reduces the need for kidney dialysis." 4. A high-carbohydrate, low-protein diet reduces nausea and vomiting."

Strategy: Think about each answer. (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 (2) hypertension related more to fluid retention as well as interruption of the renin-angiotensin cycle (3) dialysis may be needed even if client follows the proper diet (4) common signs/symptoms of ARF; dietary content will not reduce the problem; administration of antiemetic medication will be needed

When assisting in the discharge teaching of a client with type 1 diabetes, the LPN/LVN informs the client that a sandwich made with two slices of whole wheat bread, one slice of bologna, 1 tsp of mayonnaise, and two lettuce leaves is the equivalent of which of the following? 1. 1 bread exchange, 2 meat exchanges, 1/2 fat exchange, and 1 fruit exchange. 2. 2 bread exchanges, 1 meat exchange, 1 fat exchange, and 1 vegetable exchange. 3. 1 bread exchange, 2 meat exchanges, and 2 fat exchanges. 4. 2 bread exchanges, 1 meat exchange, 1 fat exchange, and 2 vegetable exchanges.

Strategy: Think about each answer. (1) Two slices of bread equals 2 bread exchanges; lettuce is a vegetable (2) CORRECT—according to the guidelines established by the American Diabetic Association, two slices of whole wheat bread equals 2 bread exchanges, one slice of bologna equals 1 meat exchange, 1 tsp of mayonnaise equals 1 fat exchange, two lettuce leaves equals 1 vegetable exchange (3) mayonnaise is the only fat exchange (4) lettuce is the only vegetable exchange

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

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

A client with type 1 diabetes mellitus is placed on a diet of 1,800 calories/day. The LPN/LVN instructs the client that which of the following foods 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.

Strategy: Think about each answer. (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 client diagnosed with acute renal failure (ARF). The client's family shares with the LPN that the client does not want to maintain bedrest. Which of the following responses by the LPN/LVN is BEST? 1. "I will talk with the physician to see if the client can be up as tolerated." 2. "Clients with acute renal failure are prone to falling." 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."

Strategy: Think about each answer. (1) should be on bedrest to reduce the demand on the impaired kidney (2) because of reduced levels of erythropoiesis, client will have reduced RBCs; can be at risk for falling but is not rationale for bedrest (3) CORRECT—goal is to reduce the demand on the impaired kidney; function can improve with acute renal function (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

The LPN/LVN tests a child's urine for specific gravity, color, and clarity. Which of the following reports would the LPN/LVN consider normal? 1. 1.020, yellow, clear. 2. 1.005, deep orange, clear. 3. 1.035, deep orange, cloudy. 4. 1.001, yellow, cloudy.

Strategy: Think about each answer. (1)CORRECT—normal specific gravity is 1.010 to 1.030; urine should be clear yellow or light amber and not cloudy (2)specific gravity measures concentration of particles in the urine; high specific gravity indicates concentrated urine; low specific gravity indicates dilute urine; this urine is dilute; color of urine should be pale, straw-colored to amber, and should be transparent (3)indicates concentrated urine; cloudy urine indicates infection (4)urine very dilute; foamy urine indicates presence of protein

The LPN/LVN should explain to the client that the juice containing the MOST vitamin C is which of the following? 1. Canned apple juice. 2. Canned tomato juice. 3. Frozen grapefruit juice. 4. Fresh orange juice.

Strategy: Think about each answer. (1)contains negligible amounts of vitamin C (2)contains more vitamin C than apple juice but much less than orange juice (3)) contains vitamin C, but less than orange juice (4)CORRECT—canned juice is processed in such a way that the vitamin is partially destroyed; also true, though to less of an extent, by freezing; fresh foods contain more vitamins

The LPN/LVN identifies that which of the following changes in the pattern of urinary elimination is usually associated with aging? 1. Decreased frequency. 2. Incontinence. 3. Sphincter reflexes decrease. 4. Formation of bladder stones.

Strategy: Think about each answer. (1)increased frequency due to decreased muscle tone and decreased bladder capacity (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 (4)not a change due to aging; renal nephrons decrease in number; kidneys have more difficulty concentrating urine; has no influence on the ability to retain the normal volume of urine in the bladder before feeling the urge to void

The LPN/LVN cares for a client diagnosed with Cushing's syndrome managed with drug therapy. It is MOST important for the LPN/LVN to instruct the client about which of the following diets? 1. A diet high in carbohydrates, low in sodium. 2. A diet high in protein, low in sodium. 3. A diet low in protein, high in calcium. 4. A diet low in carbohydrates with vitamin C supplements.

Strategy: Think about each answer. (1)is prone to hyperglycemia, retains sodium (2)CORRECT—excessive protein catabolism occurs with disease; retains sodium (3)disease associated with muscle wasting and osteoporosis (4)needs to ingest an adequate amount of carbohydrates to meet needs; vitamin C could aid in wound healing

The LPN/LVN knows that serum albumin is used as an indicator of malnutrition because of which of the following? 1. Albumin from eggs is assumed to be constant in the American diet. 2. Protein is metabolized last; low levels indicate severe malnutrition. 3. Serum albumin can indicate a protein deficiency that may not be detected on physical examination. 4. Serum albumin has a short half-life, so it is an easy protein to measure.

Strategy: Think about each answer. (1)most abundant form of protein in the blood; helps maintain oncotic pressure and transport other nutrients, drugs, and hormones through the blood (2)sequence of nutrient metabolism not related to reason albumin is an effective tool for estimating client's nutritional status (3)CORRECT—serum albumin makes up 60% of the serum protein; lack of amino acids available for protein building or the inability of the liver to produce albumin; either process can result in malnutrition (4)has a long half-life; due to long half-life and large body pool, serum albumin is slow to respond to nutritional deficits

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. 3. 2,500 mL. 4. 3,000 mL.

Strategy: Think about each answer. (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 (3)typical daily urine output for an adult is 1,500 mL (4)because output is related to intake, under some circumstances, this would be considered acceptable if the intake was comparable

The LPN/LVN identifies that which of the following is a risk factor for a client to develop a decubitus ulcer? 1. The client lies on dry linens. 2. The client ambulates with an assistive device. 3. The client is diagnosed with anemia. 4. The client is diagnosed with Alzheimer's disease.

Strategy: Think about each answer. (1)prolonged contact with increased moisture will contribute to skin breakdown; ensure that clients are not sitting/lying on wet linens or dressing (2)prolonged sitting/lying without changing positions contributes to skin breakdown due to sensory loss (3)CORRECT—results in decreased oxygen-carrying capacity of the blood; anything resulting in decreased nourishment of the skin predisposes the development of pressure ulcers (4)does not predispose client to develop pressure ulcers

The LPN/LVN understands that which of the following behaviors is helpful to facilitate a client to have bowel elimination? 1. Avoid strenuous activity. 2. Eat more foods that increase bulk. 3. Decrease fluid intake to decrease urinary losses. 4. Use oral laxatives so that a bowel pattern is established.

Strategy: Think about each answer. (1)should engage in regular exercise (2)CORRECT—foods that contain cellulose, such as whole-wheat bread, fruits, and other grains, will increase the bulk in the stool (3)constipation caused by decrease in fluid intake; encourage client to drink adequate amounts of fluid (4)chronic laxative abuse exacerbates constipation

At discharge, the LPN/LVN advises a client about a calorie-restricted diet. The LPN/LVN informs the client that which of the following is an ideal rate of weight loss? 1. 0.5 lb per day. 2. 0.5 lb per week. 3. 1 lb per week. 4. 1 lb per day.

Strategy: Think about each answer. (1)weight loss is too rapid (2)ideal weight loss for overweight to mildly obese client is 1 to 2 lb per week (3)CORRECT—losing 1 to 2 lb per week is safe and effective; adult women should not fall below 1,200 calories per day; adult men should consume a minimum of 1,500 calories per day (4)weight loss is too rapid

As the LPN/LVN measures the blood pressure, the client tells the nurse that she has always had a heavy menstrual flow and needs extra iron. The LPN/LVN should recommend the client eat which of the following foods? 1. Chicken livers. 2. Pork. 3. Hamburger. 4. Tofu.

Strategy: Think about each answer. (1.) CORRECT— liver is an excellent concentrated source of iron (2.) although pork liver is an excellent source of concentrated iron, pork in general is not a concentrated source of iron (3.) because hamburger is often a mixture of vegetable fibers, fat as well as lean beef, it is not a concentrated source of iron; beef liver is a good source of iron, but does not contain as much iron as pork liver or chicken liver (4.) tofu contains concentrated iron, but chicken liver is a better source

Because the client is suspected of having cancer of the bladder, the LPN/LVN instructs the nursing assistants to monitor the client closely for which of the following MOST common signs/symptoms? 1. Hematuria. 2. Frequent urination. 3. Painful urination. 4. Left flank pain.

Strategy: Think about each answer. (1.) CORRECT— predominant sign associated with bladder cancer; hematuria may be gross and is usually intermittent (2.) may occur if has UTI; blood is rich medium for microorganism growth (3.) dysuria may be seen if infection is present (4.) indicates kidney stone

Which of the following clinical manifestations 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. 3. Hyporeflexia of the extremities. 4. Intestinal obstruction.

Strategy: Think about each answer. (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 (3.) spasms are common because of the damage to the spinal cord (4.) does not obstruct bowel patency but can result in constipation

When measuring for crutch length, the LPN/LVN should remember that the top of the crutch should be in which of the following locations? 1. 2 to 3 fingers below the axilla. 2. 5 to 6 fingers below the axilla. 3. Even with the axilla. 4. 6 inches below the axilla.

Strategy: Think about each answer. (1.) CORRECT—prevents pressure on the axillary nerve; the tips of the crutch should be 4 to 6 inches out from the sides; axilla tops and tips should be padded (2.) too low; would require stooping and increase risk of fatigue and muscle soreness (3.) would put pressure on axillary nerve, increasing risk of nerve damage (4.) too low; would require stooping and increase risk of fatigue and muscle soreness

The LPN/LVN assesses a client with a diagnosis of osteoarthritis. The LPN/LVN is MOST likely to observe which of the following signs or symptoms? 1. Pain on abduction of the hips, waddling gait. 2. Fever, rash, and nodules over bony prominences. 3. Swollen, reddened, hot, and inflamed joints. 4. Stiffness of the hips, knees, vertebrate, and fingers.

Strategy: Think about each answer. (1.) gait changes are related to pain experienced during movement or weight bearing; not a particular type of gait; nor is pain not associated with a specific joint position (2.) fever and rash consistent with systemic lupus erythematosus; nodules over bony prominences associated with rheumatoid arthritis (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 knows that an elderly client with a severe hearing deficit is MOST likely to exhibit which of the following characteristics? 1. Seeks medical attention immediately. 2. Suspicious of other people. 3. Pleased when hearing aid improves hearing. 4. Learns lip-reading and sign language.

Strategy: Think about each answer. (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 (3.) initially, most are self-conscious are about wearing hearing aid (4.) initially, most feel uncomfortable using lip-reading and sign language to communicate

After reviewing the laboratory studies of a client suspected of having renal failure, it is MOST important for the LPN/LVN to notify the supervising nurse because of which of the following? 1. A small number of WBCs (white blood cells). 2. Specific gravity of 1.011. 3. Dark amber in color. 4. Several broad granular casts.

Strategy: Think about each answer. (1.) normal finding (2.) normal laboratory study (3.) color change caused by ingestion of some drugs or can be dark amber if client is dehydrated (4.) CORRECT— casts are commonly associated with renal failure

A client diagnosed with Parkinson's disease has tremors in both upper arms. The LPN/LVN observes the tremors disappear as the client unbuttons his shirt. Which of the following statements illustrates the MOST ACCURATE understanding by the LPN/LVN about the tremors? 1. Tremors are psychological and can be controlled at will. 2. The severity of tremors decreases when attention is diverted by activity. 3. Tremors are unexplainable. 4. Tremors disappear with rest.

Strategy: Think about each answer. (1.) tremors are physiological (2.) CORRECT—clients with Parkinson's disease usually exhibit tremors only at rest; if the client is given an activity to perform, the tremors seem to go away due to the diversion (3.) decreased dopamine causes uninhibited excitatory messages by acetylcholine-producing neurons in the basal ganglia (4.) will decrease with activity

A 54-year-old client recently diagnosed with acute renal failure (ARF) is learning to live with the disease. To aid in assuring the highest quality of life, the home care LPN/LVN instructs the client to include which of the following daily activities? 1. Eat high-protein, low-carbohydrate diet. 2. Avoid large crowds and extreme temperatures. 3. Include bananas and oranges in the daily diet. 4. Weigh once weekly.

Strategy: Think about the outcome of each answer. Is it desired? (1)protein should be limited to 1 g/kg; adequate carbohydrates need to be ingested to prevent excessive metabolism of proteins (2)CORRECT—goal is to reduce metabolic rate, resulting in fewer end products for the kidneys to convert; fever related to infections will increase the metabolic rate; infectious processes will increase the metabolic rate in response to the inflammatory process (3)both are high in potassium; poorly functioning kidneys cannot excrete potassium (4)should weigh daily

When contributing to the nursing management of a client with an amputation with an immediate prosthetic fitting, the LPN/LVN expects to take which of the following nursing actions? 1. Assess drainage from Penrose drains. 2. Observe dressing for signs of excessive bleeding. 3. Elevate the residual limb on pillows for a minimum of 40 hours. 4. Provide cast care on the affected extremity.

Strategy: Think about the outcome of each answer. Is it desired? (1.) drains may be used to control hematoma if a soft dressing (dressing, and elastic bandage or stump sock) is used (2.) will have closed, rigid cast (3.) elevation of residual limb will cause contractures; if residual limb requires elevation, elevate the foot of the bed (4.) CORRECT—closed, rigid cast prevents bleeding, supports soft tissues to control pain, and will prevent contracture; because there is a rigid plaster cast, cast care is required

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 do which of the following? 1. Apply cream daily to the residual limb. 2. Cover the residual limb with a nylon sock. 3. Keep the residual limb elevated. 4. Expose the residual limb to air.

Strategy: Think about the outcome of each answer. Is it desired? (1.) prescribing is beyond the LPN/LVN role; common treatment includes washing residual limb and drying gently; assess for areas of breakdown (2.) residual limb sock should be made of cotton, which absorbs perspiration and prevents direct contact between skin and prosthetic device; to prevent infection, change sock daily (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

An older adult lives alone on a limited income. The client's diet consists primarily of carbohydrates. Which of the following actions by the LPN/LVN is MOST appropriate? 1. Instruct the client to increase intake of protein. 2. Instruct the client to reduce intake of fat. 3. Instruct the client to increase caloric intake. 4. Instruct the client to decrease fluid intake.

Strategy: Topic of question is unstated. (1)CORRECT—ensuring that the older client's intake includes adequate protein is a challenge; important for an elderly client to ingest protein to keep organs functioning, and slows down the degeneration process (2)does need to limit fat and cholesterol in the diet, but no indication that client is ingesting too much fat (3)older adults usually require fewer calories; may require increased calories if recovering from surgery or illness (4)should drink adequate amounts of water to maintain hydration

The LPN/LVN in a long-term care facility cares for a client diagnosed with a cerebrovascular accident with right hemiplegia. It is MOST important for the LPN/LVN to take which of the following actions? 1. Check the client's oral cavity for food. 2. Offer the client between-meal snacks. 3. Offer the client oral fluid q 4 hours. 4. Document the client's food intake.

Strategy: Topic of question is unstated. Read answer choices for clues. (1) CORRECT—clients with decreased motor-sensory abilities are likely to retain food in the oral cavity, resulting in increased risk of infection or aspiration (2) clients with hemiplegia likely to eat less at one time; while snacks likely to improve or maintain nutritional status, the threat of aspiration takes higher priority (3) should offer fluids more often; clients are at risk for dehydration (4) appropriate action; not as significant as ensuring client is not retaining food in the oral cavity

The LPN/LVN notes that an elderly client has a reddened area on the coccyx. Which of the following actions should the LPN/LVN take FIRST? 1. Observe the area every 4 hours. 2. Reposition the client every 1 to 2 hours. 3. Massage the reddened area four times per day. 4. Place the client in a semi-reclining position.

The LPN/LVN notes that an elderly client has a reddened area on the coccyx. Which of the following actions should the LPN/LVN take FIRST? 1. Observe the area every 4 hours. 2. Reposition the client every 1 to 2 hours. 3. Massage the reddened area four times per day. 4. Place the client in a semi-reclining position. Show/hide explanation Strategy: "FIRST" indicates priority. (1)this situation does not require further assessment (2)CORRECT—frequent change in position will relieve pressure on client's skin; encourage client to shift weight every 15 minutes; use pillow to relieve pressure over bony prominences (3)do not massage reddened area; causes damage to capillaries and deep tissues (4)causes shearing force on sacral area; shearing occurs when client is pulled or allowed to slump in the bed

The LPN/LVN cares for a client newly diagnosed with Parkinson's disease. The LPN/LVN expects to observe which of the following? Select all that apply: 1. Tremors. 2. Diplopia. 3. Bradykinesia. 4. Slurred speech. 5. Respiratory distress. 6. Propulsive gait.

Think about each answer. (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 cares for a client in the long-term care facility who is being evaluated for hypothyroidism (myxedema). The LPN/LVN should observe for which of the following signs and symptoms? Select all that apply: 1. Joint pain. 2. Sensitivity to cold. 3. Urinary frequency. 4. Diarrhea. 5. Increased fatigue. 6. Muscular twitching.

Think about each answer. (1.) because the thyroid hormone (thyroxine) participates in the body's metabolic rate, a significant sustained reduction in the serum level results in a decrease in all body activities; may complain of muscle aches and paresthesia (2.) CORRECT— due to decreased metabolic rate (3.) may have decreased urine output (4.) because of the decreased metabolic rate, is more likely to present with constipation (5.) CORRECT— decreased thyroxine levels results in decreased metabolic rate, resulting in sustained, significant fatigue; because signs and symptoms are vague, usually have disease for a period of time before it is diagnosed; the clinical picture also includes bradycardia, intolerance to the cold, dull and dry hair, alopecia, and obesity (6.) muscular twitching occurs with hypoparathyroidism due to a reduction in serum calcium

The LPN/LVN admits a new client to the long-term care facility. The LPN/LVN assesses the client's nutritional status. Which of the following observations by the LPN/LVN indicates that the client is adequately nourished? Select all that apply: 1. The client's conjunctiva is pale. 2. The client is 5 feet, 2 inches tall and weighs 125 pounds. 3. The client has spoon-shaped nails. 4. The client's hair is shiny and lustrous. 5. The client skin is rough, dry, and scaly. 6. The client's gums are pink in color.

Think about each answer. (1.) indicates anemia; if client is well nourished, eyes should be clear, bright, and shiny with pink conjunctiva (2.) CORRECT— weight should be normal for body build and age (3.) indicates iron deficiency anemia, malnutrition (4.) CORRECT— if client is malnourished, hair may be stringy, dull, dry, and thin (5.) skin should be smooth and slightly moist (6.) CORRECT— if client is poorly nourished, gums will be spongy and will bleed easily

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