NCLEX LPN Management of Care

The LPN/LVN cares for clients in the outpatient clinic. Several clients exhibit signs/symptoms that may indicate early stage cancer. Although all of the clients are instructed to make appointments with their personal health care providers, the LPN/LVN STRONGLY encourages which of the following clients to make an IMMEDIATE follow-up appointment? 1. A client who complains of heavy menstrual periods. 2. A client who tests positive for occult blood in stool. 3. A client who develops spoon-shaped nails. 4. A client who has an increased white blood cell count.

Strategy: "Immediate" indicates priority. (1.) may indicate uterine cancer or fibroids (2.) can have variable meanings; could be upper gastric bleeding from PUD or could be colon cancer (3.) CORRECT— early indication of lung cancer; number-one cause of cancer deaths (4.) can indicate inflammatory or infectious process, as well as leukemia

A client diagnosed with a duodenal ulcer has surgical repair of the perforated site. The client has a nasogastric tube (NG), an IV of 1,000 cc D5 1/2 Ringer's lactate at 80 mL/hr, and a Penrose drain inserted in the wound. Because the client finds the patent NG tube very uncomfortable, she asks the LPN/LVN to remove the tube "right now." Which of the following actions by the LPN/LVN is MOST appropriate? 1. Refuse to remove the tube. 2. Assess the contents of the drainage. 3. Explain why tube is necessary. 4. Inform client that physician will not permit removal of the tube.

Strategy: "MOST appropriate" indicates discrimination may be required to answer the question. (1) needs to address the client's discomfort (2) tube is patent; drainage needs to be assessed, but need to help client adjust to the discomfort (3) CORRECT—explain that without the tube gastric contents will be expelled via vomiting, which will result in extreme pressure on the suture line, as well as the significant discomfort associated with vomiting; solutions are available that would increase client comfort (4) NG output is measured and included in the overall output; health care team not as interested in gastric juice volume as they are in maintaining the operative site

The community health LPN/LVN assists a bedridden client to manage peripheral edema associated with heart disease. It is MOST important for the LPN/LVN to include which of the following statements when instructing the client? 1. "Eat smaller feedings more frequently." 2. "Regular exercise plays an important role in reducing the retention of fluid in your body." 3. "Your legs swell more than the rest of your body because of the effects of gravity." 4. "If your feet are still swollen after a good night's sleep, the problem is related to the heart."

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1.) CORRECT— requires less effort to eat; offer foods that have a relatively soft texture and encourage client to eat slowly (2.) because peripheral edema is often related to renal or cardiac disease, regular exercise does not contribute significantly to reduction in fluid volume (3.) true of ambulating client; bedridden client retains fluid near sacral area (4.) if peripheral edema is related to venous insufficiency, fluid in legs and feet may resolve during the night while the legs are at the same level as the heart

The LPN/LVN in the outpatient clinic cares for a client who is diagnosed with hepatitis A. The client relates to the nurse that she is the single parent of five children under the age of 9 and that she is unable to care for the children due to the illness. The client decides that her children should stay with their father until she recovers. It is MOST important for the LPN/LVN to take which of the following actions? 1. Determine where the client contracted hepatitis A. 2. Remind the client to send the children's favorite toys with them. 3. Inform the client that her children have already been exposed and should remain with her. 4. Instruct the client to dispose of sanitary napkins by placing them in separate plastic bag.

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1.) although relevant to disease control, is not the LPN/LVN's priority; primary focus is to help children adapt to being away from their mother (2.) CORRECT— during a crisis, children are often comforted and soothed by familiar items; maintains a degree of connection with the old environment (3.) children may or may not be infected; signs/symptoms include fatigue and malaise; client may not feel well enough to provide for five small children; no food preparation allowed during illness (4.) is transmitted via enteric route; hepatitis B is transmitted via serum

The LPN/LVN receives report about clients in the long-term care facility. Which of the clients should the LPN/LVN see FIRST? 1. A client undergoing bowel prep complains of watery diarrhea. 2. A client falls and complains of pain in the right ankle. 3. A client who had a cataract extraction 3 days ago complains of nausea. 4. A client with a spinal cord injury at the level of C7 complains of a headache.

Strategy: Determine the most unstable client. (1.) expected outcome (2.) assess pulses, temperature of extremity; elevate and place ice on ankle; contact the physician; is not the priority client (3.) second client to see; vomiting increases intraocular pressure, which will affect the suture line (4.) CORRECT— headache indicates autonomic dysreflexia; ensure that catheter is draining appropriately and the client's bowels are not impacted

The LPN/LVN cares for clients on the medical/surgical floor. The LPN/LVN determines assignments are appropriate if which of the following clients is assigned to the LPN/LVN? 1. A client returns after an appendectomy complicated by a pneumothorax during surgery. 2. A client with increased intracranial pressure who responds to painful stimuli. 3. A client diagnosed with cellulitis receiving antibiotics. 4. A client with a mandibular fracture immobilized by wiring the jaw prepares for discharge.

Strategy: LPN/LVN cares for stable clients with expected outcomes. (1.) requires assessment and nursing judgment; assign to RN (2.) requires assessment and nursing judgment; assign to RN (3.) CORRECT — stable client with expected outcome (4.) requires discharge teaching regarding importance of oral hygiene and nutrition

The LPN/LVN contributes to the initial assessment of a client in the outpatient clinic with a diagnosis of R/O ulcerative colitis. It is MOST important for the LPN/LVN to instruct the nursing assistants to report which of the following sign/symptoms of ulcerative colitis? 1. Rigid abdomen with rebound pain. 2. Black tarry stool specimen. 3. Frank bleeding in the stool. 4. Vomitus containing bright red blood.

Strategy: Think about each answer and how it relates to ulcerative colitis. (1) associated more with ruptured appendix (2) more likely to occur with upper gastrointestinal bleeding (3) CORRECT—disease damages the superficial tissue of the intestinal mucosa; bleeding can be minor or severe (4) more common in peptic ulcer disease or upper GI bleeding; ulcerative colitis involves intestines

An LPN/LVN assists in the outpatient clinic with the care of clients diagnosed with gastrointestinal (GI) alterations. The LPN/LVN identifies that which of the following client diagnoses has the GREATEST risk of impairing the client's health status? 1. A client diagnosed with multiple diverticula of the colon. 2. A client diagnosed with dental caries. 3. A client diagnosed with gastroesophageal reflux disease (GERD). 4. A client diagnosed with a hiatal hernia.

Strategy: Think about each answer. (1.) sacs or pouches in the intestinal wall; clients are generally asymptomatic; associated signs/symptoms include weakness, fatigue, and anorexia; diverticula can become inflamed; diagnosis and treatment can be delayed unless signs/symptoms developed (2.) dental cavities; can interfere with mastication and become painful; unless experiencing severe pain, could be delayed until GERD and hiatal hernia are managed (3.) CORRECT— because esophageal tissues are not designed to receive gastric contents, esophagus is at risk for tissue erosion; H. pylori associated with cancer are known to grow in the eroded tissue subjected to gastric contents (4.) 50% of clients are asymptomatic; others report frequent heartburn, regurgitation, and dysphagia; has a high degree of discomfort along with risk of tissue erosion after meals if client does not remain in upright position; this effortless regurgitation can even occur when the client is in an upright position

A client with severe diverticulitis is admitted to the hospital for bowel surgery, and a colostomy is performed. Which of the following observations of the stoma would cause the LPN/LVN to reassure the client that the stoma is normal? 1. The stoma is bluish and dry. 2. The stoma is beefy-red. 3. The stoma is gray and small. 4. The stoma is dark and pulsating.

A client with severe diverticulitis is admitted to the hospital for bowel surgery, and a colostomy is performed. Which of the following observations of the stoma would cause the LPN/LVN to reassure the client that the stoma is normal? 1. The stoma is bluish and dry. 2. The stoma is beefy-red. 3. The stoma is gray and small. 4. The stoma is dark and pulsating.

A 32-year-old client is scheduled for a mammogram. The client states, "My breasts are so large, I'm afraid they won't be able to do the test." Which of the following responses by the LPN/LVN is BEST? 1. "Don't worry, they have done this procedure many times." 2. "The size of your breasts will not affect the test." 3. "I'll notify your physician so that a biopsy can be scheduled instead." 4. "Many women feel the same way you do."

Strategy: "BEST" indicates discrimination is required to answer the question. (1) nontherapeutic; negates the client's feelings (2) CORRECT—mammography is x-ray of the soft tissue of the breast and can detect cancer that is not palpable; size of breast does not matter (3) LPN/LVN should respond therapeutically to client's response (4) nontherapeutic; LPN/LVN should respond to client; this is a closed response

Because a client is diagnosed with end stage liver disease, the LPN/LVN knows which of the following should be included in the nursing care plan? 1. Administer aspirin for pain. 2. Administer fat-soluble vitamin supplements. 3. Monitor serum amylase levels. 4. Monitor serum calcium levels.

Strategy: Think about the outcome of each answer. (1) aspirin increases clotting time; clients with impaired liver function are at risk for bleeding (2) CORRECT—impaired liver function results in reduced ability to synthesize fat-soluble vitamins; client will need additional volume to meet basic nutritional needs (3) more commonly associated with pancreatic disease (4) because of the risk of hyperphosphotemia, changes in calcium levels are more commonly associated with renal disease

The LPN/LVN cares for clients in the long-term care facility. When delegating care of clients to other staff members, the LPN/LVN should utilize which of the following techniques? Select all that apply: 1. The LPN/LVN maintains eye contact with the staff member. 2. The LPN/LVN asks staff members to report any problems. 3. The LPN/LVN states what, how, and when a task should be performed. 4. The LPN/LVN tells the nursing staff that feedback is not required after completing care. 5. The LPN/LVN tells the staff the reason the task is to be completed. 6. The LPN/LVN tells the staff to establish a timeline to complete the task.

Determine the outcome of each answer. Is it desired? (1.) CORRECT— eye contact is important; state exactly what is being delegated and what the expected outcome is, convey recognition of the authority to perform what is expected (2.) delegator should clearly define complications and the appropriate action(s) for the staff to take if complications occur (3.) CORRECT— delegator should obtain feedback to ensure the staff understands the assignment; identify priorities, acknowledge monitoring activities required, specify any performance limitations (such as time limits), specify deadlines, specify report timelines and data expected, specify parameter deviations (including when immediate action must take place), and be clear about what may not be delegated (4.) feedback is essential to ensure continuity of care; inform staff if a verbal or written report is required at completion of task (5.) CORRECT— gives incentive to the staff for accepting responsibility and authority for completing the task (6.) describing expected outcome and timeline for completion of the task is the responsibility of the delegator

ecause of damage to the liver related to hepatitis C, a client is placed on the waiting list for an organ transplant. The client reports to the LPN/LVN the greatest challenge is dealing with the fatigue and the boredom. Which of the following interventions by the LPN/LVN is BEST? 1. Help the client recognize the physical limitations. 2. Encourage the client to be patient, because he may have to wait for a long time. 3. Determine if liver damage is progressing. 4. Help client identify valued activities in which to engage.

Strategy: "BEST" indicates discrimination is required to answer the question. (1.) best to list activities, then separate inappropriate from appropriate (2.) better to teach client to deal with a long waiting period rather than simply encouraging to be patient (3.) because liver gradually deteriorates, is appropriate to note liver status; does not assist client with managing fatigue and boredom (4.) CORRECT — boredom likely to be decreased if client is performing highly valued activities; boredom can often drain energy

A male client with a family history of inguinal hernias has surgical repair of a left inguinal hernia for the second time. He tells the LPN/LVN he is afraid that his 3-month-old daughter will inherit the problem. Which of the following responses by the LPN/LVN is BEST? 1. "It is more appropriate if we talk about that later." 2. "Males are more prone to inguinal hernias than females." 3. "You should have your daughter assessed as soon as possible." 4. "What makes you think your daughter is likely to develop the problem?"

Strategy: "BEST" indicates discrimination may be required to answer the question. (1) is best to respond to question when client expresses concern (2) CORRECT—can be hereditary; but intestines often push through the inguinal ring because it did not close appropriately following passage of the testicles while in utero (3) rarely develops in females but may develop because of obesity, pregnancy, or a muscular weakness accompanied by sustained increased intra-abdominal pressure (4) reflective response is inappropriate; with family history of problem and second surgery, it is reasonable to be concerned about child having the same experience; because it's not likely, appropriate response could relieve undue stress

The LPN/LVN assists in the management of the health care of an older adult client suspected of having syndrome of inappropriate antidiuretic hormone (SIADH). The LPN/LVN is MOST concerned if which of the following is observed? 1. The client's serum sodium level is 137 mEq/L. 2. The client is drinking water. 3. The client is oriented to person, place, and time. 4. The client is lying in bed with the rails up.

Strategy: "MOST concerned" indicates something is wrong. (1.) normal range for sodium is 135 to 145 mEq/L (2.) CORRECT— SIADH causes a dilutional hyponatremia; water intake monitored closely (3.) would indicate the absence of cerebral edema commonly associated with excessive fluid retention related to SIADH (4.) implement safety measures to prevent injury caused by potential changes in level of consciousness

The LPN/LVN discusses radioactive implant treatment with the client and her family. The LPN/LVN should provide which of the following instructions? 1. Visits will be discontinued until after the treatment is completed. 2. Treatment will be temporarily discontinued to permit family visits. 3. Family visits are encouraged during treatment. 4. Visits must be limited and brief during treatment.

Strategy: Determine the outcome of each answer. Is it desired? (1)limit visitors to half-hour per day; must stand at least 6 feet from the source of radiation (2)able to visit for short periods of time (3)can visit for half-hour per day (4)CORRECT—visitors and staff should decrease the time spent and keep a safe distance from the implant

After the LPN/LVN completes the hospital health history form for a client suspected of having cirrhosis, the LPN/LVN should post which of the following signs above the head of the client's bed? 1. "Seizure precautions." 2. "Do not raise head of bed." 3. "No IM injections." 4. "No blood pressures in left arm."

Strategy: Think about the outcome of each answer. (1) clients with cirrhosis may have mental changes associated with increased serum ammonia (NH3) levels, but risks of seizures are not as common as risk of excessive bleeding (2) more appropriate for clients with damaged or fractured spines (3) CORRECT— because the liver contributes to the production of clotting factors, clients with liver damage are more prone to bleeding; IM injections should be avoided to prevent excessive bruising or bleeding (4) more appropriate for postmastectomy clients

The LPN/LVN is assigned to care for a client requiring a dressing change. The LPN/LVN tells the supervising nurse that the LPN/LVN observed a similar dressing change while in nursing school but has never performed the procedure. The supervising nurse should take which of the following actions? 1. Ask the LPN/LVN to review the hospital's procedure manual regarding dressing changes. 2. Review the steps of the dressing change with LPN/LVN. 3. Complete the dressing change this time and ask the LPN/LVN to observe. 4. Assign a more experienced LPN/LVN to the client.

Strategy: Think about the outcome of each answer. (1)demonstration/return demonstration is more effective teaching tool than reading about procedure (2)important, but LPN/LVN should demonstrate (3)CORRECT—this accomplishes two goals: completing the dressing change and helping the LPN/LVN to learn how to do the procedure (4)it is the supervising nurse's responsibility to instruct the staff about procedures and care of clients

The LPN/LVN is asked by the health care provider to assist with a lumbar puncture. It is MOST important for the LPN/LVN to take which of the following actions? 1. Inform the supervising nurse. 2. Inform the assigned nursing assistants. 3. Inform assigned team of clients. 4. Encourage client to take slow, deep breaths.

Strategy: Topic of question unstated. (1) CORRECT—procedure takes 20-30 minutes; client will need assistance lying motionless; LPN/LVN will need to remain with client; assigned clients will need care while LPN/LVN is occupied with procedure; transfers duties to appropriate level (2) chain of command requires LPN/LVN to report to supervisor (3) notifying clients would delegate the responsibility of their care to themselves (4) would help client relax and reduce movement; needs to make sure other clients' needs are met before beginning procedure that will cause LPN/LVN to be inaccessible for 20-30 minutes

The LPN/LVN cares for clients in the long-term care facility. The LPN/LVN identifies which of the following clients as likely to develop a potassium imbalance? Select all that apply: 1. A client diagnosed with chronic renal failure. 2. A client diagnosed with osteoarthritis. 3. A client experiencing vomiting and diarrhea. 4. A client receiving furosemide (Lasix). 5. A client recovering from a cerebrovascular accident. 6. A client diagnosed with Parkinson's.

Think about each answer. (1.) CORRECT— renal failure causes hyperkalemia; symptoms include dysrhythmias, muscle weakness, paralysis (2.) osteoarthritis is progressive cartilage deterioration in the synovial joints and vertebrae; does not affect potassium balance (3.) CORRECT— causes hypokalemia; indications include anorexia, nausea, vomiting, muscle weakness, paraesthesias (4.) CORRECT— potassium-wasting diuretic that causes hypokalemia (5.) does not cause a potassium imbalance (6.) caused by a deficiency of dopamine; does not cause a potassium imbalance

On the day of discharge, a client newly diagnosed with diabetes says, "Tell me again, what should I do if I develop a fever?" Which of the following is the BEST response by the LPN/LVN? 1. "Increase your caloric intake and decrease your insulin dosage." 2. "Discontinue taking insulin until after your febrile state has passed." 3. "Continue to monitor blood sugar and take insulin as prescribed." 4. "See your physician to have your insulin dosage adjusted."

Strategy: "BEST" indicates discrimination may be required to answer the question. (1.) need for insulin increases during illness; should test blood glucose every 3 to 4 hours; if usual meal plan can't be followed, substitute soft foods (2.) fever increases metabolic rate and release of glucose; need to continue taking insulin (3.) CORRECT — diabetic's need for insulin is increased with any concurrent illness, especially an infection; presence of a fever, inability to ingest food, and erratic blood glucose levels are all reasons for an immediate call to the physician (4.) contact physician if unable to control glucose level using guidelines provided

When assessing a client admitted with a severe headache and a body temperature (tympanic membrane) of 102.7 F (39.3 C), the LPN/LVN notes that when the client's head is flexed, the client flexes the hips and knees. Which of the following activities by the LPN/LVN is BEST? 1. Immediately notify the assigning nurse. 2. Continue with the nursing assessment. 3. Administer medication prescribed for the pain. 4. Place the client in high Fowler's position and start oxygen at 2 L.

Strategy: "BEST" indicates priority. (1) CORRECT—suspicion of meningitis, a life-threatening illness, should be reported to the appropriate person immediately (2) client could be infectious, which poses a threat to other clients and staff members (3) attending to client pain should be addressed, but the threat to the client, other clients, and staff members should be addressed first (4) client at risk for increased intracranial pressure, should have the head of the bed raised but not high Fowler's; extreme hip flexion increases intra-abdominal pressure and intrathoracic pressure, which can increase intracranial pressure; signs/symptoms should be monitored and supplemental oxygen applied when needed; is not a need at this time

Because blood has been oozing continuously from the vagina of a postoperative client after a vaginal hysterectomy, 2 units of whole blood are ordered. As the LPN/LVN collects the pre-transfusion vital signs, the client states she does not want the blood transfusions because of religious beliefs. Which of the following responses by the LPN/LVN is BEST? 1. Instruct the client to discuss the matter with the surgeon. 2. Immediately report the information to supervising nurse. 3. Assure the client that the blood has been carefully screened. 4. Explain the importance of replacing the blood lost after surgery.

Strategy: "BEST" indicates that discrimination may be required to answer the question. (1.) LPN should report to supervising nurse; supervising nurse will talk with client and report to physician (2.) CORRECT— client has the right to refuse treatment; LPN/LVN should honor religious beliefs; report to supervising nurse, who will inform client about outcome of the refusal of treatment; health care provider will be notified (3.) presumes the client is concerned about contamination (4.) disregards client's religious beliefs; client has the right to make health care decisions

The LPN/LVN cares for a client just admitted with sickle cell anemia crisis. Which of the following actions should the LPN/LVN take FIRST? 1. Administer prescribed pain medication. 2. Prevent ulcer formation. 3. Administer prescribed antibiotic. 4. Maintain hydration.

Strategy: "FIRST" indicates priority. (1) CORRECT—clients often report for health care because of the severe pain; pain is related to hypoxia caused by crowding of sickle-shaped RBCs in small blood vessels (2) ulcer formation on lower limbs is related to decreased circulation; because of the severity of the pain, it needs to be addressed first (3) particularly susceptible to pneumonia; medications for pain relief should take priority, followed by administration of prescribed antibiotics (4) because of the severity of sickle cell crisis, hydration is important; IV infusions are often prescribed; the severe pain should be addressed first

The LPN/LVN notices that an intravenous infusion is not running. Which of the following actions should the LPN/LVN initiate FIRST? 1. Reposition the client's arm. 2. Check the site. 3. Raise the IV solution. 4. Flush the tubing.

Strategy: "FIRST" indicates priority. (1) appropriate action after assessment of the site (2) CORRECT—when an intravenous infusion stops running, infiltration is the most common cause; by checking the site, can ascertain whether the infusion has infiltrated; if no infiltration is present, then the LPN/LVN can reposition arm or raise solution; symptoms of infiltration include edema, pain, coolness of site, decrease in flow rate (3) to determine if IV has infiltrated, apply tourniquet above the infusion site; if infusion continues to drip, it is infiltrated (4) flushing the tubing is not recommended unless a thrombolytic drug is used

The LPN/LVN leads a smoking cessation class. Which of the following instructions should the LPN/LVN give FIRST? 1. "Remove ashtrays and lighters from view." 2. "Go to places that tempt you to smoke to test your resolve." 3. "Make a list of all of the reasons to quit smoking." 4. "Drink at least 8 glasses of water per day."

Strategy: "FIRST" indicates priority. (1) client must first be motivated to quit smoking; removing ashtrays and lighters removes a visual stimulation to smoke (2) should avoid places that tempt a person to smoke; develop new routines during times that a person used to smoke (3) CORRECT—client has to have a willingness to learn and to change behavior; if the client is not motivated to change, instructing him about how to change will be unsuccessful; always assess the client's willingness to learn (4) good health practice; with physician's approval, begin exercise program

The LPN/LVN performs a home care visit to a middle-aged female client diagnosed with iron-deficiency anemia. The client states that even though she is taking her "iron pill" daily, she is feeling more and more fatigued. Which of the following actions should the LPN/LVN take FIRST? 1. Instruct the client to balance rest and activity. 2. Ask about characteristics of menses. 3. Contact the physician. 4. Instruct the client about eating foods high in iron.

Strategy: "FIRST" indicates priority. (1) fatigue is a major symptom of anemia, and it is appropriate to balance rest and activity; since most common cause is bleeding, warrants further investigation (2) CORRECT—major cause of iron deficiency anemia in adults is bleeding; middle-aged females likely to be experiencing menopause with irregular periods with some heavy bleeding (3) complete assessment first (4) iron-deficiency anemia caused by inadequate intake of iron for hemoglobin synthesis; LPN/LVN assumes that cause of weakness is lack of dietary iron; need to determine cause of fatigue

The LPN/LVN cares for a client 24 hours post appendectomy. The client has severe abdominal pain, a temperature of 101°F (38.2°C), and a rigid abdomen. Which of the following actions should the LPN/LVN take FIRST? 1. Assist the client with ambulation down the hallway. 2. Assess the client's level of pain. 3. Assess the client's bowel sounds. 4. Assess the wound for odor and drainage.

Strategy: "FIRST" indicates priority. (1) more appropriate if client experiences abdominal pain related to excessive flatus (2) appendectomy, if appendix not ruptured, normally does not result in severe pain; especially not 24 hours postop; pain only along with sympathetic response would be the expected clinical picture (3) CORRECT—peritonitis can be caused by ruptured appendix; signs and symptoms of peritonitis include severe abdominal pain, abdominal rigidity, decreased bowel sounds, nausea and vomiting, increased temperature, shock, paralytic ileus; monitor vital signs, administer antibiotics and IVs, NG tube to suction, NPO, surgery to correct cause (4) not likely to have odor and drainage the day after surgery; if signs and symptoms of peritonitis, impaired bowel sounds are likely; paralytic ileus is likely and life-threatening

While monitoring a client receiving an intravenous infusion of doxorubicin (Adriamycin), the LPN/LVN notes that the infusion rate has decreased, and the client's hand is slightly swollen. Which of the following actions should the LPN/LVN take FIRST? 1. Increase the infusion rate. 2. Stop the infusion. 3. Apply warm compress to the hand and continue the infusion. 4. Apply cold compress to the hand and continue the infusion.

Strategy: "FIRST" indicates priority. (1) swollen hand indicates that IV has infiltrated; doxorubicin (Adriamycin) is a chemical that causes tissue damage on direct contact; causes pain, infection, and tissue loss; stop the IV immediately and apply ice to site for 24 to 48 hours (2) CORRECT—doxorubicin (Adriamycin) will cause tissue damage; after applying ice, monitor site closely, because extravasation may be progressive; doxorubicin (Adriamycin) is an antibiotic antineoplastic; side effects include red urine, nausea, vomiting, stomatitis, alopecia, cardiotoxicity, and bone marrow depression; nursing considerations include check EKG, avoid infiltration, monitor vital signs closely, and give good mouth care (3) stop infusion due to infiltration; apply ice (4) stop infusion due to infiltration; apply ice

The LPN/LVN cares for clients in a physician's office. Four clients are waiting to see the physician. The LPN/LVN should ask the physician to see which of the following clients FIRST? 1. A 50-year-old who is diaphoretic and complaining of nausea. 2. A 60-year-old with a history of asthma complaining of a productive cough. 3. A 65-year-old complaining of a temperature of 101 ° F (38 ° C). 4. A 70-year-old complaining of vaginal bleeding.

Strategy: "FIRST" indicates priority. (1.) CORRECT— Although most clients who experience a heart attack complain of some type of chest discomfort, some clients present with slightly atypical symptoms; client should be treated as a potential MI, and a cardiac evaluation should be performed immediately (2.) has a history of asthma, and therefore, increased risk of respiratory compromise; a productive cough alone (indicative of a probably upper respiratory infection) does not take precedence over the patient with a potential MI; treatment of the URI with antibiotics and a MDI will likely prevent an asthma exacerbation (3.) potential MI takes priority (4.) vaginal bleeding after menopause can indicate cancer of uterus; biopsy or aspiration will be done

After making rounds, the LPN/LVN needs to report status changes on several clients to the supervising nurse. The LPN/LVN should report which of the following changes FIRST? 1. A client who has developed an irregular heart rhythm. 2. A client whose serum high-density lipids is 170 mg/dL. 3. A client who has slight oozing of blood from a cardiac catheterization site. 4. A client who has inflammation at the insertion site of total parenteral nutrition (TPN) catheter.

Strategy: "FIRST" indicates priority. (1.) CORRECT— can be drug-induced or related to cardiac hypoxia or cardiac damage; because any sign of pump failure could be life-threatening, needs to be addressed immediately; because etiology is not known, would need involvement of physician and complex assessment methods along with potentially complex interventions (2.) within normal limits; HDL levels are not as health-impairing as LDL (3.) although could become life-threatening, can be resolved by reapplying dressing without additional input from physician (4.) can develop sepsis, but no immediate life-threatening risks exist

The LPN/LVN in the outpatient clinic cares for a client who is receiving enalapril (Vasotec) 10 mg PO BID. Despite the medication, the client's blood pressure continues to range from 165/98 to 179/100. The LPN/LVN learns the client is not taking the medication because he has been "cured" through spiritual healing. Which of the following actions should the LPN/LVN take FIRST? 1. Consult with the supervising nurse. 2. Teach the client about the importance of taking the medication. 3. Inform the client that spiritual healing has not lowered his blood pressure. 4. Talk to the spiritual leader about the client's blood pressure.

Strategy: "FIRST" indicates priority. (1.) CORRECT— client requires more in-depth assessment (2.) primary focus is to determine the relationship between the client's interpretation of the spiritual healing and the current status of the blood pressure (3.) need to consult with supervisor before challenging client's spiritual or religious beliefs; guideline indicates health care workers should respect client's beliefs, but doing so places this client at risk (4.) does not maintain client confidentiality

The community health LPN/LVN plans visits for the day. Which of the following clients should the LPN/LVN see FIRST? 1. A client diagnosed with type 2 diabetes who is complaining of GI upset after taking chlorpropamide (Diabinese). 2. A client complaining of vomiting after chemotherapy. 3. A client with a tonometer reading of 21 mm Hg. 4. A client with a laryngectomy who is complaining of a greenish-yellow discharge.

Strategy: "FIRST" indicates priority. (1.) Diabinese is an oral hypoglycemic; side effects include diarrhea, GI upset, and hypoglycemia; administer in divided doses to relieve GI upset; does not require immediate attention (2.) common side effect of chemotherapy; does not require immediate attention (3.) used to diagnose glaucoma; tonometer measures intraocular pressure; normal IOP reading is 10 to 21 mm Hg (4.) CORRECT— most unstable patient; assess breath sounds and amount, color, and character of drainage

The LPN/LVN begins the shift by assessing the clients. After making rounds, the LPN/LVN should FIRST contact the physician about which of the following clients? 1. A client with an obvious deformity of the right humerus. Extremity is warm to the touch with a palpable pulse. 2. A client is unconscious. Heart rate is 64 bpm and regular, and respirations are even and unlabored. 3. A client has multiple superficial scalp lacerations. Client is alert and responsive. 4. A client is restless. Client is pale, skin is cool and clammy, and abdomen is rigid with absent bowel sounds.

Strategy: "FIRST" indicates priority. (1.) although the client likely has a fracture that will require further stabilization, there is no evidence of neurovascular compromise at present; does not take priority (2.) although the client is unconscious, cardiopulmonary assessment is stable; does not take priority (3.) although client may have circulatory compromise, the client is alert; ask nursing assistant to apply pressure to any areas where bleeding is not well controlled; requires further evaluation but does not take priority at this time (4.) CORRECT— appears to have severe circulatory compromise; most unstable client

A client diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH) exhibits signs and symptoms commonly associated with the disease. Which of the following assessments should the LPN/LVN focus on FIRST? 1. Amount of weight the client gained. 2. An increase in the client's blood pressure. 3. Status of the client's nervous system. 4. The client complains of abdominal cramping.

Strategy: "FIRST" indicates priority. (1.) clients' responses to weight gain vary; some will gain significant amounts without significant impact on health status; others will gain lesser amounts with significant impact on their health status (2.) blood pressure will increase with fluid retention; is relevant indicator of the magnitude of the disease; does not provide data that would guide nursing activities to prevent permanent damage to client (3.) CORRECT— increased fluid volume results in hypo-osmolar or solute free fluid which enters cerebral cells more readily than other body cells, resulting in edematous nonfunctioning cells; cerebral edema can place client at extreme risk for permanent brain damage or death (4.) this sign/symptom is uncomfortable and needs to be addressed; does not tell the LPN/LVN that client may be at extreme ris

The LPN/LVN cares for clients in the long-term care facility. The nursing assistant reports that four clients are complaining of pain. Which of the following clients should the LPN/LVN see FIRST? 1. A client with a history of a herniated lumbar disc complaining of severe pain radiating down the left leg. 2. A client with a history of migraine headaches complaining of a headache with light sensitivity. 3. A client with a history of kidney stones is tearful and complaining of severe right flank pain. 4. A client with a history of coronary artery disease (CAD) complaining of midepigastric pain radiating to the neck.

Strategy: "FIRST" indicates priority. (1.) condition is chronic; does not take priority (2.) likely experiencing a migraine headache; does not take priority (3.) important to address this client's pain and assess for symptoms of obstruction of the ureter; symptoms that may indicate myocardial infarction take priority (4.) CORRECT— history of CAD increases risk of myocardial infarction; pain that originates in the chest or abdomen and radiates to the neck, shoulder, or arm requires immediate evaluation

The LPN/LVN cares for clients in the gynecological clinic. Which of the following clients should the nurse see FIRST? 1. A 60-year-old female complaining of dry vaginal wall and painful intercourse. 2. A 35-year-old female post-hysterosalpingogram who is experiencing tachycardia and a generalized rash. 3. A 30-year-old female requiring preparation for a cervical biopsy. 4. A 25-year-old female scheduled for a Pap smear.

Strategy: "FIRST" indicates priority. (1.) does not require immediate attention; instruct about water-soluble lubricants (2.) CORRECT— an x-ray of the cervix, uterus, and fallopian tubes performed after the injection of a contrast medium; assess for allergy to shellfish or iodine; requires immediate attention because client is having an allergic reaction (3.) does not require immediate attention; physician usually performs a biopsy as a follow-up to suspicious Pap test findings (4.) exam to detect precancerous and cancerous cells from the cervix; does not require immediate attention

The LPN/LVN receives patient assignments from the charge nurse and prepares to make rounds on the assigned patients. Which of the following patients should the LPN/LVN see FIRST? 1. A patient with normal saline infusing IV at 125 ml per hour and complains of slight swelling at the IV insertion site. 2. A patient 3 days post right-knee replacement complaining of right calf pain with movement. 3. A patient drinking contrast for an abdominal CT scan and complains of nausea. 4. A patient with a respiratory rate of 24 and an oxygen saturation of 94% on room air.

Strategy: "FIRST" indicates priority. (1.) important to assess the site for the patient's comfort and to prevent complications associated with IV infusion (2.) CORRECT— assess for possible DVT, report immediately to supervising nurse; possibility of a blood clot that not only impacts circulation, but also the potential to impact the patient's respiratory status, takes precedence (3.) although symptom management is important to patient comfort and to insure the patient is able to complete the contrast for the test, a potentially life-threatening condition takes precedence (4.) respiratory status is stable at present

The home health LPN/LVN arrives at the home of a post-myocardial infarction client. The LPN/LVN notes that the client's right leg is swollen and the client is crying because she thinks a swollen leg indicates her heart is failing. Which of the following actions should the LPN/LVN take FIRST? 1. Ensure that the client is knowledgeable about the prescribed medication. 2. Assess for signs and symptoms of depression. 3. Contact the physician. 4. Instruct the client to elevate the leg.

Strategy: "FIRST" indicates priority. (1.) is part of managing a post-MI client, but does not take priority in this situation (2.) based on data, client is crying because of swollen leg (3.) CORRECT— CHF can be a complication of MI, but bilateral lower-limb edema is usually seen; unilateral edema is commonly associated with obstructed blood vessel(s) on the affected side; this is a serious sign/symptom and warrants immediate attention (4.) etiology is currently unknown; teaching will be appropriate after diagnosis made and treatment prescribed

The LPN/LVN cares for clients in the long-term care facility. After receiving report, which of the following clients should the LPN/LVN see FIRST? 1. A client due to receive blood pressure medicine. 2. A client due to receive a metered dose inhaler (MDI). 3. A client whose family member is threatening to sue the institution if the LPN/LVN doesn't talk to them immediately. 4. A client who has been verbally abusive to staff and is becoming increasingly more agitated.

Strategy: "FIRST" indicates priority. (1.) safety takes precedence over administration of routine; non-emergent medications (2.) safety takes precedence over administration of routine; non-emergent medications (3.) although angry, the family member does not pose an immediate physical threat to the clients, staff, or other visitors (4.) CORRECT— client poses a potentially immediate physical threat to himself, staff members, and/or other clients and visitors if the situation is allowed to escalate further; intervene and initiate protocols prescribed by the individual facility to maintain a safe environment

The LPN/LVN cares for clients in the long-term care facility. After receiving report, which of the following clients should the LPN/LVN see FIRST? 1. A client with right-sided weakness requires assistance with A.M. care. 2. A client requires administration of digoxin (Lanoxin) and furosemide (Lasix). 3. The daughter of a client is upset because her father is diagnosed with terminal cancer. 4. A client is suddenly confused and sees spiders on the wall.

Strategy: "FIRST" indicates priority. (1.) stable client (2.) medications usually given once per day; no indication client is unstable (3.) physical needs take priority over psychosocial needs (4.) CORRECT— sudden confusion and hallucinations indicate delirium, which is a medical emergency

The LPN/LVN initiates the discharge plan developed by the assigned nurse for the family of a client diagnosed with hepatic encephalopathy. Further teaching is necessary if the family makes which of the following statements to the LPN/LVN? 1. "We should contact the physician if Dad is restless at night." 2. "Lactulose (Cephulac) will cause Dad to have 2 to 3 stools per day." 3. "Dad should eat meat at every meal." 4. "Lactulose (Cephulac) may cause bloating and cramps."

Strategy: "Further teaching is necessary" indicates incorrect information. (1) hepatic encephalopathy occurs with profound liver disease and results from the accumulation of ammonia in the blood; earliest symptoms are mental changes; will exhibit periods of lethargy and euphoria; progresses to coma (2) laxative that promotes excretion of ammonia in the stools; side effects include cramping, belching, and diarrhea; very sweet tasting, dilute with fruit juice; do not use other laxatives in addition to Cephulac (3) CORRECT—low-protein, high-calorie diet; instruct family to observe for and report mental changes (4) side effect of drug; lasts about a week and then disappears

The home health LPN/LVN instructs the parents of an 11-year-old client about the prescribed antidepressants. The LPN/LVN determines further teaching is necessary if the client's mother states the following? 1. "This drug will take a long time to become effective." 2. "I am looking forward to my child getting better so he can stop taking the medication." 3. "I will encourage my child to drink plenty of water." 4. "I will administer the medication at night."

Strategy: "Further teaching is necessary" indicates incorrect information. (1.) therapeutic effectiveness takes 3 to 6 weeks for many drugs in this category (2.) CORRECT— depression in childhood is generally chronic and requires continuous treatment (3.) many antihypertensives cause constipation as a side effect; increased fluids and roughage can reduce or eliminate the problem (4.) many antihypertensives cause drowsiness; appropriate action

The LPN/LVN assists the school nurse to care for students in the local high school. A student tells the LPN/LVN that the student's mother has been diagnosed with terminal cancer. Which of the following behaviors, if displayed by the student, should cause the LPN/LVN to report to the school nurse immediately? 1. The student is sad and cries frequently. 2. The student has lost 10 pounds and appears very sleepy. 3. The student is frequently absent and has declining grades. 4. The student appears happy and gives valued items to close friends.

Strategy: "IMMEDIATELY" indicates priority. (1.) behaviors commonly associated with anticipated loss of significant other (2.) loss of appetite resulting in weight loss is anticipated; may also have difficulty sleeping (3.) decreased energy with loss of interest in normal activities together with reduced ability to concentrate is associated anticipatory grief (4.) CORRECT — when planning suicide, clients often display exhilarated mood and offer valued possessions to close friends or family members; suicide rates are high among adolescents

A young adult with hemophilia bumps his knee and develops painful swelling of the knee. In caring for the client, which of the following actions is MOST appropriate for the LPN/LVN to take initially? 1. Apply ice to the client's knee and elevate the leg. 2. Prepare the client for blood administration. 3. Explain the client's limitations to him. 4. Administer analgesics for pain.

Strategy: "Initially" indicates priority. (1) CORRECT—hemophilia is a sex-linked recessive trait transmitted to males by female carriers; deficiency of factor VIII; abnormal bleeding in response to trauma; signs include easy bruising, joint pain with bleeding, and prolonged internal or external bleeding; instruct client to institute supportive measures when trauma occurs—rest, ice, compression, and elevation (RICE); applying ice to his knee and elevating his leg is the most appropriate action to take initially because it will help to stop the bleeding and decrease the swelling; will also help to alleviate the pain (2) administering factor VIII cryoprecipitate is more appropriate; transfusions are more relevant after significant bleeding (3) most important to institute measures to prevent bleeding; assessment of how trauma occurred and how it can be prevented after bleeding is controlled (4) bleeding into joints and muscles can be painful; most important to control bleeding

The LPN/LVN makes a home visit to a client receiving chemotherapy for the treatment of cancer. The LPN/LVN instructs the client about ways to avoid injury due to bone marrow suppression. The LPN/LVN should intervene if which of the following is observed? 1. The client takes Alka-Seltzer for indigestion. 2. The client uses an electric razor to shave. 3. The client blows his nose gently. 4. After bumping his leg, the client applies ice for an hour.

Strategy: "Should intervene" indicates a complication. (1) CORRECT—should not take medications that contain aspirin due to danger of bleeding; Alka-Seltzer contains aspirin (2) appropriate action (3) appropriate action; instruct not to block either nasal passage while blowing (4) appropriate action; instruct not to participate in contact sports

he health care of a 9-year-old client with sickle cell anemia is being managed at home. It is MOST appropriate for the LPN/LVN to teach the child and parents about which of the following? 1. The child can lead a normal life. 2. The child will need daily folic acid supplements. 3. Vitamin B12 cannot be absorbed from the stomach. 4. Report any signs/symptoms of infection.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) all of the health care focuses on helping client lead a normal life in spite of the disease; does not provide parents with data to help them make appropriate decisions about the client's health care (2) more appropriate for hemolytic anemia or clients with alcoholism; folic acid contributes to the production of RBCs; this disease causes impairments because of the abnormal shape, not the number of, RBCs (3) more appropriate for pernicious anemia; vitamin B12 contributes to the production of RBCs; a deficit results in anemia; the outcome of this disease is related to the shape of the RBC (4) CORRECT—infectious processes are the primary causes of deaths in children with sickle cell anemia

The LPN/LVN participates in the discharge planning for a 76-year-old client diagnosed with anemia related to inadequate dietary intake. Because the client lives alone, which of the following suggestions by the LPN/LVN is MOST appropriate? 1. "Invite others over during mealtime." 2. "Meals-on-Wheels can provide meals for you." 3. "Is there someone available to grocery shop for you?" 4. "Why are you not eating?"

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) eating with another person may help increase the client's intake, but client must assume the responsibility for meals (2) CORRECT—elderly individuals often do not prepare wholesome meals; anemia results in reduced energy and client will be less likely to prepare meals (3) preparation of meals is more of an issue than procurement of groceries (4) do not ask "why" questions

Ondansetron HCl (Zofran) 6 mg PO q 6 hr is ordered for a client. The LPN/LVN knows that which of the following times is the MOST appropriate to administer this medication? 1. 1 hour after chemotherapy. 2. 30 minutes before start of chemotherapy. 3. 2 hours after chemotherapy. 4. When the client complains of nausea.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) too late; goal is to prevent nausea, not treat nausea (2) CORRECT—ondansetron HCl (Zofran) is a potent antiemetic with a 30- to 40-minute onset of action; side effects include constipation, diarrhea, fever, lightheadedness, and drowsiness (3) client may already be nauseated; given to prevent nausea (4) assist client to reduce anxiety by progressive muscle relaxation, guided imagery, or distraction

An LPN/LVN answers the call light of a client diagnosed with Addison's disease. The client suddenly begins vomiting and reports feeling light-headed. The MOST appropriate nursing action by the LPN/LVN includes which of the following? 1. Lower the head of the bed and cover the client with blankets. 2. Measure the client's blood pressure and perform finger stick for blood sugar. 3. Administer prn antiemetic medication. 4. Assess components of the vomitus.

Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1.) places client at risk for aspiration; disease usually results in circulatory shock, blankets could decrease loss of body heat (2.) CORRECT— exhibiting signs/symptoms of Addisonian crisis; hypotension and hypoglycemia are common S/S; should perform these activities while having someone notify the supervising nurse of the client's change in status (3.) should act to reduce vomiting; Addisonian crisis is a life-threatening alteration; more important to eliminate or validate possible shock (4.) systemic response to sudden decrease in cortisol is more important than assessing contents of vomitus

After administering pain medication to a client, which of the following actions is MOST appropriate for the LPN/LVN to take? 1. Do not disturb the client until the pain medication is due again. 2. Keep the environment cool and quiet for the rest of the day. 3. Provide diversional activities at short intervals. 4. Evaluate whether the medication is effective.

Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. (1)should avoid disturbing, but evaluate if medication is effective (2)make the environment comfortable for the client (3)should determine drug effectiveness; the interest in diversional activities may be related to the intensity and duration of the pain (4)CORRECT—imperative that client be evaluated for the therapeutic physiological and psychological effects responses to pain medication

An LPN/LVN cares for residents in an assisted living facility. The LPN/LVN discovers an unconscious client lying on the floor beside the bed with a small, open lesion on the right side of the head. After caring for the client, the LPN/LVN prepares to write an incident report. Which of the following entries is MOST appropriate for the incident report? 1. "The client apparently fell out of bed." 2. "Notified supervisor of the accidental head injury." 3. "Apparently struck right side of head during fall." 4. "Nonresponsive client found lying on floor beside bed."

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) nurse did not make this observation; should only chart the facts (2) documenting notification of supervisor is appropriate for nurses' notes; no data to support conclusion of accidental head injury (3) no evidence that client fell nor that the head was struck in the process (4) CORRECT—incident should reflect exactly what the person completing the report saw, heard, touched, etc.

The LPN/LVN receives a phone call from a young adult diagnosed with type 1 diabetes treated with humulin insulin. Because the client experienced decreased sexual abilities, he began taking an herbal supplement that he learned about when watching television. Which of the following responses by the LPN/LVN is MOST appropriate? 1. "It is a good idea for you to see a physician about your sexual problems." 2. "Is the medication helping you with the problem?" 3. "Stop taking the medication until you can consult with your physician." 4. "Did your blood sugar change after you started taking the herb?"

Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1.) because this appears important to the client, teaching is relevant; priority includes interrupting current behavior that may place the client at risk (2.) because most herbs are marketed without research, the herb's effectiveness is irrelevant; insulin interacts with many drugs (3.) CORRECT— because client is not knowledgeable about either the disease or the global impact of drugs, it is important to communicate this information to the health care provider (4.) even if glucose level is unaffected, too many unknowns exist for client to continue ingesting the drug

The LPN/LVN cares for a client diagnosed with polycythemia vera. It is MOST important for the LPN/LVN to instruct the nursing assistants to perform which of the following? 1. Massage the lower limbs vigorously during the morning bath. 2. Assist the client with long, early morning walks. 3. Apply antipruritic lotion after completing the client's bath. 4. Measure vital signs q 4 hours.

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) polycythemia is an increased volume of red blood cells; because of the increased number of RBCs, client is at risk for clot formation; vigorous massage is contraindicated (2) because of excessive RBCs, client will have reduced oxygen exchange, resulting in fatigue, intermittent claudication, and dyspnea; extensive exercise is contraindicated (3) CORRECT—increased histamine release related to the increased production of basophils results in generalized pruritus, a common discomfort (4) because of increased viscosity, client is at risk for clotting formation, resulting in a CVA or an MI, but no need to measure vital signs unless client exhibits signs/symptoms of circulatory impairment

The LPN/LVN assists in the management of the home care of an elderly client who has had pernicious anemia for 10 years. Because of a common complication associated with the disease, it is MOST important that the LPN/LVN instruct the client about which of the following procedures? 1. Gastroscopy. 2. Liver biopsy. 3. Complete blood count. 4. Bone marrow transplant.

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) CORRECT—clients with pernicious anemia are more prone to gastric cancer and generally assessed via gastroscopy every 1 to 2 years (2) although RBC production is affected by this disease, the problem does not originate in the liver (3) excessive RBCs is a common sign/symptom of the disease, not a complication of the disease; CBC would not provide information about gastric cancer, which is a common life-threatening complication (4) although the disease is characterized by the bone marrow producing an excessive volume of RBCs, phlebotomy is the most common medical intervention

The LPN/LVN cares for an obese client diagnosed with autoimmune thrombocytopenic purpura. Because the client is immobile, it is MOST important for the LPN/LVN to give the nursing assistants which of the following instructions? 1. "Use a turn sheet when repositioning the client." 2. "Set up contact isolation precautions." 3. "Help the client floss his teeth." 4. "During transfer to a chair, do not allow weight bearing."

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) CORRECT—pressure applied using the hand can result in extensive bruising; use of turn sheet distributes pressure widely with the risk of less damage to the tissues (2) be aware of the risk for injury; client is not infectious (3) may cause bleeding; avoid constipation, straining with stool, flossing, hard toothbrushes, and safety razors (4) diagnosis of autoimmune thrombocytopenic purpura will not prevent weight bearing; thrombocytopenia causes a low platelet count

During a home visit, a client diagnosed with AIDS reports experiencing fatigue and shortness of breath during normal daily activities. During client teaching, it is MOST important for the LPN/LVN to include which of the following instructions? 1. Suggest the client request occupational therapy. 2. Instruct the client to sit while preparing meals. 3. Instruct the client to perform all activities in the morning. 4. Suggest to the client that he accept the limitations.

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) LPN/LVN should assist the client to manage reduced energy levels (2) CORRECT—energy conservation technique; sitting while washing is also helpful; place frequently used personal items within client's reach (3) should balance rest and activity (4) should instruct client in ways to improve activity tolerance

Family members are having difficulty communicating with a client with confusion due to AIDS dementia complex. It is MOST important for the LPN/LVN to take which of the following actions? 1. Ask the client to identify the day and date. 2. Assist the client to answer questions asked by the family. 3. Give the client simple directions. 4. Explain the day's schedule during breakfast.

Strategy: "MOST important" indicates discrimination is required to answer the question. (1) cognitive manifestations of AIDS dementia complex include slowed thinking, memory loss, loss of concentration, and confusion; frequently reorient client to person, place, and time; use calendars and clocks; this answer is gathering data, and this situation does not require validation (2) client's thinking is slowed; give client sufficient time to respond to questions (3) CORRECT—use short, uncomplicated sentences; orient to daily activities by explaining the activities while they are happening (4) post a daily schedule in a prominent place; client may not be able to process or remember what is being said

Immediately following a liver biopsy, the LPN/LVN administers morphine sulfate 3 mg IM to the client. It is MOST important for the LPN/LVN to instruct the nursing assistants to perform the following? 1. Make sure client remains on the right side. 2. Keep client positioned on the left side. 3. Instruct client to remain prone for 4 hours. 4. Assist client into the supine position.

Strategy: "MOST important" indicates discrimination is required. (1) CORRECT— after a liver biopsy, this position is important to prevent leakage of fluid or hemorrhage from occurring; because of this, the ideal position is to lie directly on the liver with the ribs pushing on the liver; place a pillow under costal margin; after receiving morphine sulfate, client may change position while sleeping (2) liver is on the right side; put pressure on the liver to prevent hemorrhage; instruct client to avoid coughing or straining (3) risk of hemorrhage is a primary risk; nursing activity should provide conditions that prevent the development of the risk (4) in supine position with right arm raised above the head for biopsy; instruct client to inhale and exhale several times; have client inhale, exhale, and then hold breath for insertion of biopsy needle

The LPN/LVN on the medical surgical unit has just received report. Which of the following clients should the LPN/LVN see FIRST? 1. A client one day post-op after an appendectomy. 2. A client who had a detached retina surgically repaired 4 hours ago. 3. A client with an esophagogastric tube inserted. 4. A client 2 days post-op after a laminectomy with spinal fusion.

Strategy: Determine the most unstable client. (1.) stable client (2.) administer analgesics and antiemetics as prescribed; report increase in pain and instruct client not to bend from waist, cough or sneeze, or strain to have a bowel movement (3.) CORRECT— used to treat bleeding esophageal varices; assess vital signs for decreased blood pressure and elevated pulse; ensure that balloon pressure and volume is maintained (4.) maintain body alignment; assess for sensation and circulatory status of lower extremities

The LPN/LVN cares for a middle-aged adult diagnosed with Buerger's disease. Because of rapid progression of the disease, the client's wife and three adolescent children begin working to meet the family's financial needs. After observing the client and his family at home, it is MOST important for the LPN/LVN to report which of the following information to the supervising nurse? 1. The client spends most of the day on the internet. 2. At times the client is verbally abusive to his wife. 3. The client watches television most of the day. 4. The client is withdrawn and sleeps most of the day.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1.) may indicate maladaptive coping, but can be a distractor from the pain associated with the disease (2.) CORRECT — without intervention, verbal abuse can progress to physical abuse; can migrate to the children also (3.) may indicate maladaptive coping; often takes several months to adjust to extensive role changes (4.) illustrates signs/symptoms of clinical depression, which is common following a significant loss

A client with a history of migraine headaches is diagnosed with viral hepatitis. It is MOST important for the LPN/LVN to perform which of the following client teaching? 1. "Do not take Tylenol for the headaches." 2. "You may have a glass of wine with meals." 3. "If your hands are kept clean, you may wear artificial nails." 4. "Wash hands thoroughly before eating or drinking."

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) CORRECT—Tylenol is contraindicated because it is hepatotoxic; instruct client to avoid all medications unless prescribed by the physician (2) alcohol damages liver cells (3) presence of bile salts in skin causes pruritus; instruct client to keep nails short; apply calamine lotion (4) instruct about the importance of personal hygiene; hand washing is the greatest preventive method for reducing the spread of infection; not related to headaches and hepatitis

The clinic LPN/LVN is assisting a client manage the challenges of the diagnosis of hepatitis B. It is MOST important for the LPN/LVN to encourage the client to discuss which of the following with the physician? 1. Serum anti-delta antibodies. 2. Thorough hand washing after evacuation of stool. 3. Serum cholesterol. 4. BUN.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) CORRECT—clients with hepatitis B are prone to develop hepatitis D; antibodies for the delta virus confirms the diagnosis (2) is transmitted via contact with blood (3) blood lipid synthesized by liver; desired level is <200 mg/dL (4) urea is end product of protein metabolism; excreted by kidneys; range is 5-25 mg/dL

The LPN/LVN who is assisting the school nurse is informed that a sixth grader in the school has been diagnosed with hepatitis A. It is MOST important for the LPN/LVN to reinforce instructions about which of the following measures to prevent hepatitis A? 1. Wash hands thoroughly after using the bathroom. 2. Avoid contact with blood-contaminated items. 3. Purchase protective masks for school. 4. Withdraw child from school for three weeks.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) CORRECT—transmitted via the fecal-oral route (2) is transmitted by fecal-oral route (3) is not transmitted via droplets (4) incubation period is 10-50 days; with preventive methods, no need to withdraw from school; if infected, may need to withdraw until recovered

A female client in a residential care facility has a urinary tract infection (UTI). It is MOST important for the LPN/LVN to instruct the client about which of the following? 1. Take medication with food. 2. Douche once or twice a week. 3. Keep bowels soft. 4. Empty bladder on a regular basis.

Strategy: "MOST important" indicates discrimination may be required to answer the question. (1.) not necessary for some drugs; the goal is to reduce or prevent the disease process (2.) reduces normal flora in vagina, predisposing to vaginitis, which can predispose to UTIs (3.) constipation has no direct relationship on the development of UTIs; would be more appropriate to advise client to cleanse rectal area after a bowel movement from the front to the back (4.) CORRECT— urinary stasis and dehydration in the older adult contribute to the development of UTIs

The LPN/LVN makes a monthly assessment of a 77-year-old client in the long-term care facility. It is MOST important for the LPN/LVN to report which of the following assessments to the health care provider? 1. The client has lost 6 pounds in 4 weeks. 2. The client's dentures do not fit properly. 3. The client complains of a hard, painless ulcer between the tongue and the floor of the mouth. 4. The client appears to have difficulty hearing when the TV is turned on.

Strategy: "MOST important" indicates priority. (1.) weight loss probably related to ill-fitting dentures; requires follow-up, but mouth ulcer takes priority (2.) improperly fitting dentures can cause tissue breakdown, interfere with mastication, and cause weight loss; risk of dropping dentures, which requires expensive repairs (3.) CORRECT— indicative of possible oral cancer; common areas include lips, lateral aspect of tongue, and floor of mouth; predisposing factors include alcohol and tobacco use (4.) decreased hearing often related to aging process; can be augmented with prosthesis; places client at risk for sensory deprivation

Which of the following nursing actions is MOST important for the LPN/LVN to take to provide effective pain relief for a client? 1. Teach the client about pain. 2. Establish a trusting relationship with the client. 3. Determine how various relaxation techniques affect the pain. 4. Administer pharmacological agents.

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1)important to convey to the client in pain that the LPN/LVN believes the client's pain is real and that the LPN/LVN determines the effectiveness of the intervention for pain on the basis of the client's response (2)CORRECT—to effectively develop a plan of care for relieving a client's pain, trust is essential; pain is subjective, therefore decisions are based solely on client's report (3)is appropriate action, but LPN/LVN first establishes a trusting relationship (4)common pharmacological agents include aspirin, Tylenol, NSAIDs, and opiates; drug therapy is more effective when communication of needs is accurate

During an extremely busy time during the shift, a middle-aged client is admitted to the unit with menorrhagia. It is MOST important for the LPN/LVN to instruct the nursing assistant to perform which of the following activities? 1. Ask the client if the vaginal discharge has decreased during the previous 2 hours. 2. Measure vital signs q 3 hours if the bleeding continues. 3. Report the amount of vaginal discharge q 2 hours. 4. Collect the client's sanitary napkins in a plastic bag and to give them to the LPN/LVN.

Strategy: "MOST important" indicates that discrimination is required to answer the question. (1.) not the most accurate assessment; LPN/LVN should directly view quantity of bleeding (2.) vital signs is not most direct indication of bleeding; observe how much the client is bleeding (3.) improper delegation of a nursing activity; nursing assistant does not have the skill level to assess how much the client is bleeding; nursing assistant performs standard, unchanging procedures (4.) CORRECT— enables LPN/LVN to make direct determination about the blood loss; LPN/LVN should validate conclusions with RN

The LPN/LVN learns during the change-of-shift report that a client with a "do not resuscitate" advance directive was resuscitated by a nursing assistant. To prevent this from happening again, it is MOST important for the LPN/LVN to recommend which of the following to the supervising nurse? 1. Remind staff about the advance directives at the beginning of each shift. 2. Place a sign about the advance directive above each client's bed. 3. Attach a small blue banner to appropriate clients' bedside stands and wheelchairs. 4. Check the client's chart before initiating resuscitation.

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1.) advance directive is a written statement by a competent person that states decisions about an individual's treatment in the event of a serious illness or injury; all staff members do not receive report on every client; may not be able to recall the information during a crisis (2.) does not maintain client confidentiality (3.) CORRECT— staff would recognize that the client has advance directive; errors could still occur but this will reduce the risk (4.) need a way to provide immediate communication of the information so that staff can initiate CPR on clients without advance directives

An LPN/LVN implements the nursing care plan designed for a client diagnosed with angina pectoris. It is MOST important for the LPN/LVN to include which of the following instructions? 1. "It is safe to take brisk, short walks during the winter months." 2. "If you continue to have chest pain after taking 3 nitroglycerin tablets, notify your physician." 3. "Beta-adrenergic blocking drugs such as propranolol (Inderal) cause dilation of cardiac blood vessels." 4. "It is best for you to avoid ingesting large, heavy meals.

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1.) any activity that decreases circulation to the heart and diverts blood to other areas can place the client at risk for angina pectoris; brisk walks during winter months can shunt blood to the voluntary muscles (2.) no response after 3 tablets indicates intervention is not sufficient to meet the need; calling physician is not the BEST intervention to meet the need; physician may not be available, which would result in loss of precious time; should contact EMS immediately (3.) drugs reduce O 2 consumption by blocking sympathetic stimulation of the cardiac muscle; incorrect information; indicative of vasodilators (4.) CORRECT— large meals result in shunting of blood to the GI tract, resulting in decreased circulation to the heart and putting the client at risk for cardiac ischemia

The LPN/LVN cares for clients in the outpatient clinic. A client with a freshly placed cardiac pacemaker becomes angry when he learns that he must discontinue playing football with his sons. It is MOST important for the LPN/LVN to take which of the following actions? 1. Instruct the client to report bilateral lower-limb edema. 2. Assess for elevated blood pressure. 3. Assist the client to identify interests in alternative activities. 4. Warn client of the consequences of failure to adhere to the guidelines.

Strategy: "MOST important" indicates that discrimination may be required to answer the question. (1.) more commonly associated with heart failure (HF) (2.) hypertension not necessarily associated with client's requiring a cardiac pacemaker (3.) CORRECT— less likely to continue feeling angry if can find alternate activity with sons to replace current activity (4.) threats are more likely to increase agitation; offers no solution to the problem

To effectively control the MOST common complication associated with long term total parenteral nutrition (TPN), the LPN/LVN is MOST LIKELY to instruct the nursing assistants to perform which of the following? 1. Report signs/symptoms of respiratory distress. 2. Measure finger stick blood glucose q 4 h. 3. Report venipuncture site redness and edema. 4. Report weight gain >3 lb/daily.

Strategy: "MOST likely" indicates discrimination may be required to answer the question. (1) fluid overload can result in a bounding pulse, shortness of breath, rales, or jugular vein distention; is not as common as hyperglycemia (2) CORRECT— TPN contains 50% glucose; the body must produce insulin in response to the glucose level; need to monitor serum glucose level (3) indicative of IV site infection; long term is generally administered via a central line; infection is not the most common complication of TPN (4) TPN generally given to re-establish or maintain nutritional status; 3-lb weight gain in 24 hours is within normal range; 5 lb or more is considered excessive

The LPN/LVN notes that the serum sodium level of a client diagnosed with heart failure (HF) is decreased. Which of the following activities should the LPN/LVN perform NEXT? 1. Notify the health care provider. 2. Assess the client's lung sounds and respiratory rate. 3. Assess for peripheral edema. 4. Compare current weight to the weight of the day before.

Strategy: "NEXT" indicates priority. (1.) hyponatremia is commonly associated with HF, related to hemodilution (2.) because of decreased pump efficiency, fluid retention is common in CHF, which could result in respiratory congestion (3.) right-sided heart failure could occur related to decreased pump failure; peripheral edema occurs (4.) CORRECT— rapid weight gain can occur with HF, related to retention of free water resulting in hyponatremia; is best indicator of the etiology of the hyponatremia and takes priority; LPN/LVN should closely monitor disease progression

The LPN/LVN instructs staff members about the care of a client diagnosed with cancer of the cervix. The client has internal radiation in place. The LPN/LVN should intervene if a staff member makes which of the following statements? 1. "I should allow the client to bathe herself." 2. "I should not stand at the foot of the bed." 3. "I should place all linens in a special, lead-lined hamper." 4. "I should wear a dosimeter while I am in the client's room."

Strategy: "Should intervene" indicates an incorrect action. (1)allow client to perform as much of her own care as possible so that the staff is exposed to the radiation a minimum amount of time; client on complete bedrest to prevent dislodgement of the implant (2)do not stand in the line of radiation; organize tasks to limit time spent in the room (3)CORRECT—sheets are not radioactive; save all dressing and bed linens in the room until after the implant is removed; dispose in the usual manner (4)measures the amount of radiation to which the staff is exposed; each staff member caring for the client will have her/his own badge

The LPN/LVN cares for clients in the outpatient clinic. A client who had a bone marrow biopsy two days ago contacts the LPN/LVN for reassurance that he is caring for the aspiration site appropriately. The LPN/LVN should intervene if the client states which of the following? 1. "A warm bath feels good." 2. "I am taking aspirin for the discomfort." 3. "I walked one mile on the treadmill today." 4. "I have increased my intake of fruits and fresh vegetables."

Strategy: "Should intervene" indicates something is wrong. (1) bone marrow biopsy performed to assess quality and quantity of each type of cell produced within the marrow; warm bath appropriate to decrease any discomfort (2) CORRECT—slight risk of bleeding after procedure; aspirin alters platelet function and should not be used; can take acetaminophen (3) no reason to intervene (4) good health promotion habits; no reason to intervene

The LPN/LVN cares for clients on the night shift at the long-term care facility. After receiving report, the LPN/LVN should delegate which of the following clients to a nursing assistant with 20 years of experience? 1. Assess the breathing pattern of a client who experienced an acute asthma attack 12 hours ago. 2. Monitor a client who is expectorating rust-colored sputum. 3. Administer codeine to a terminal client. 4. Bathe a patient before the patient is transported for a scheduled 9 A.M. surgery.

Strategy: Assign clients with standard, unchanging procedures. (1.) counting respirations can be delegated to nursing assistant; this client requires assessment (2.) indicates pneumonia (3.) LPN/LVN will administer medication (4.) CORRECT— standard, unchanging procedure; nursing assistants perform direct patient care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height and weight, intake and output, housekeeping, transporting stable patients, and stocking supplies

The LPN/LVN returns to the desk in the prenatal clinic and finds four phone messages. Which of the following messages should the LPN/LVN return FIRST? 1. A multigravida at 12 weeks gestation experiencing heavy, white vaginal discharge. 2. A primigravida at 17 weeks gestation states that she has not felt the baby move. 3. A primigravida at 22 weeks gestation complains of feeling dizzy and clammy when lying on her back. 4. A multigravida at 32 weeks gestation experiencing malaise and bilateral dependent and facial edema.

Strategy: Determine the most unstable client. (1.) leukorrhea caused by hyperplasia of vaginal mucosa; normal finding (2.) normal finding for primigravida (3.) vena cava syndrome; instruct client to lie on side (4.) CORRECT— symptoms of preeclampsia that require evaluation

The home care LPN/LVN reports to the supervising nurse about four clients seen today. The LPN/LVN should FIRST report about which of the following clients? 1. A client diagnosed with lung cancer refused chemotherapy today. 2. A client asks when staples can be removed from the abdominal incision. 3. A client with a colostomy complains that the skin is raw around the stoma. 4. A client diagnosed with a cerebrovascular accident refuses a bath.

Strategy: Determine the most unstable client. (1.) CORRECT — assess whether client is experiencing side effects (2.) should ask client if incision is red or if there is any drainage (3.) second client; call to be returned; ensure that skin sealant does not contain alcohol and instruct client to use stoma powder or paste (4.) stable client

The LPN/LVN cares for clients in the long-term care facility. After receiving report, which of the following clients should the LPN/LVN see FIRST? 1. A client with a hemoglobin of 6.9 g/dL. 2. A client with an oxygen saturation of 93% on 2 liters oxygen per nasal cannula. 3. A client requesting medication for nausea. 4. A client complaining of abdominal pain and requesting pain medication.

Strategy: Determine the most unstable client. (1.) CORRECT— assessment of the client's respiratory status required; acute onset of anemia, as well as patients with concomitant disease, may experience SOB, dyspnea, and/or chest pain; oxygen supplementation is often indicated prophylactically, even if the patient is asymptomatic (2.) respiratory status is stable at present, although additional interventions may be required if the client's oxygen saturation decreases further; continue to closely monitor the client (3.) although symptom management is important for client comfort, respiratory status takes precedence (4.) although symptom management is important for client comfort, respiratory status takes precedence

The LPN/LVN cares for clients in the long-term care facility. Which of the following clients should the LPN/LVN see FIRST? 1. A client diagnosed with type 2 diabetes has pale, cool skin and is complaining of a headache. 2. A client diagnosed with a CVA has frequent watery diarrhea. 3. A client diagnosed with asthma has labored breathing. 4. A client diagnosed with chronic renal failure has a B/P of 150/90 mm Hg.

Strategy: Determine the most unstable client. (1.) experiencing hypoglycemia; offer client a glass of milk (2.) second client to be seen; at risk for dehydration (3.) CORRECT — place client on oxygen; assess breath sounds (4.) no indication client is unstable

The LPN/LVN cares for clients in the long-term care facility. After receiving report, which of the following clients should the LPN/LVN see FIRST? 1. A client diagnosed with type 2 diabetes has pale, cool skin and is complaining of a headache. 2. A client diagnosed with type 1 diabetes has a fruity breath smell and is drinking large quantities of water. 3. A client diagnosed with type 2 diabetes has a B/P of 120/50 mm Hg and is urinating frequently. 4. A client diagnosed with type 1 diabetes has a B/P of 90/60 mm Hg and skin is hot and dry to touch.

Strategy: Determine the most unstable client. (1.) indicates hypoglycemia (2.) CORRECT — indicates metabolic acidosis from ketosis (3.) symptoms of diabetes (4.) indicates dehydration caused by hyperglycemia; first stage of diabetic ketoacidosis

The LPN/LVN cares for clients in the long-term care facility. Which of the following clients should the nurse see FIRST? 1. A client diagnosed with irritable bowel syndrome complains of cramping and loose stools 2. A client diagnosed with a CVA complains of not having a bowel movement in 2 days. 3. A client receiving digoxin (Lanoxin) complains of nausea and vomiting. 4. A client with an indwelling Foley catheter asks to use the urinal.

Strategy: Determine the most unstable client. (1.) symptoms of irritable bowel syndrome; encourage patient to eat meals at regular intervals, chew food slowly, and not drink fluids with meals (2.) determine normal bowel pattern; encourage fluids, foods high in roughage (3.) CORRECT— indicates toxicity; withhold dose and notify the health care provider (4.) may be having bladder spasms; symptoms of dig toxicity takes priority

The LPN/LVN assists the ostomy nurse to teach a client with a sigmoid colostomy about how to perform a colostomy irrigation. Which of the following actions should the LPN/LVN demonstrate during the teaching session? 1. Dilate the stoma gently with gloved finger. 2. Irrigate the colostomy using 30 cc of normal saline. 3. Continue irrigating until all stool is removed. 4. Returns should occur 5 to 10 min after instilling water.

Strategy: Determine the outcome of each answer. (1) CORRECT—to prevent restriction of the size of the opening, dilating the stoma gently with a gloved finger is part of routine colostomy irrigation procedure (2) fill irrigation container with 500 to 1,000 cc lukewarm water; bottom of irrigation container should be at shoulder height (3) instill fluid over 5 to 10 min; usually takes 10 to 15 min for return (4) solution instilled for 30 to 45 min before returns begin

The client returns to a long-term medical inpatient unit after a gastroscopy is performed. The LPN/LVN instructs the nursing assistants to perform which of the following? 1. Provide client with a pitcher of ice water after the gag reflex returns. 2. Place the client in the Trendelenburg position for three hours. 3. Report abdominal cramping and distention. 4. Measure the client's vital signs q 2 h.

Strategy: Determine the outcome of each answer. Is it desired? (1) CORRECT—viscous lidocaine (Xylocaine), which decreases swallowing abilities, is utilized to provide ease of instrument insertion; should not drink until gag reflex returns (2) gag reflex is impaired; places client at risk of aspiration; procedure does not place client at risk for reduced circulation to the brain or cause a significant change in circulatory status (3) discomfort associated more with examination of the intestines (4) procedure does not cause cardiovascular compromise

After a gastrectomy for stomach cancer, a nursing assistant tells the LPN/LVN the nasogastric tube is "plugged up" and the client reports severe nausea. It is MOST important for the LPN/LVN to perform which of the following actions? 1. Irrigate the nasogastric tube immediately. 2. Notify the supervising nurse. 3. Advance the tube if coughing partially expels it. 4. Place client in supine position.

Strategy: Determine the outcome of each answer. Is it desired? (1) do not irrigate the tube unless there is an order (2) CORRECT—because irrigating the tube can put pressure on the suture line, never irrigate the tube unless it is specifically ordered; the supervisor will notify the assigned physician (3) should consult with supervising nurse; the physician should be contacted; advancing tube may rupture suture line (4) common position of NG tube is semi-Fowler's; prevents or reduces risk of aspiration should vomiting occur

The home care LPN/LVN visits a client after discharge from a rehabilitation center. The client is diagnosed with head injury and is depressed because he has difficulty going out. The client cannot tolerate environmental stimuli, such as the noise in grocery stores and malls and at school activities. Which of the following interventions by the LPN/LVN is BEST? 1. Suggest the client remain in his home until his noise tolerance improves. 2. Contact the health care provider for a prescription for an antidepressant. 3. Instruct the client to wear headphones with music playing when he goes out. 4. Recommend that the client seek psychotherapy.

Strategy: Determine the outcome of each answer. Is it desired? (1) need exposure to develop increased tolerance (2) antidepressant may increase mood level but does not address the central problem (3) CORRECT—decreases sensory input with some degree of exposure, allows client to participate in desired activities; head injuries cause clients to have decreased tolerance to sensory stimulation; can be managed with gradual exposure (4) does not have clinical depression; needs method to participate in desired activities

A client experiences numbness and decreased sensation in both lower extremities during the course of treatment with vinblastine (Velban). The LPN/LVN should include which of the following nursing actions when caring for the client? 1. Soak both legs in hot water qid. 2. Increase walking to three times a week for 30 minutes. 3. Instruct client to ambulate carefully with broad-based gait. 4. Elevate the client's legs while sitting.

Strategy: Determine the outcome of each answer. Is it desired? (1) vinblastine (Velban) is a vinca alkaloid; side effects include nausea, vomiting, stomatitis, and peripheral neuropathy; will cause extravasation; if it occurs, stop IV and apply moderate heat to the area of leakage (2) instruct client to report signs and symptoms of infection and bleeding (3) CORRECT—loss of reflexes and peripheral neuritis are potential side effects of the plant alkaloid vinblastine (Velban); may cause stumbling and falls (4) appropriate action for dependent edema

The home care LPN/LVN visits a client undergoing external radiation for treatment of lung cancer. It is MOST important for the LPN/LVN to instruct the client about which of the following? 1. Use a washcloth to gently cleanse the irradiated area. 2. Apply cream to the irradiated area daily. 3. Apply sunscreen to the irradiated area if exposed to the sun. 4. Use a patting motion to dry the irradiated area.

Strategy: Determine the outcome of each answer. Is it desired? (1)wash gently with water or mild soap and water daily; washcloth too irritating, use hand (2)do not use powders, ointments, lotions, or creams on the irradiated area (3)do not expose area to sun or to heat (4)CORRECT—after washing, pat dry with soft towel or cloth; wear soft clothing that does not bind or rub

The LPN/LVN cares for a client complaining of sudden onset of severe right flank pain. The client is diagnosed with urinary calculi. Which of the following nursing actions has the HIGHEST priority? 1. Ensure the client remains NPO. 2. Strain the urine through several layers of gauze. 3. Assess the client's grip strength and pupil reactivity. 4. Obtain a clean-catch urine specimen.

Strategy: Determine the outcome of each answer. Is it desired? (1.) force fluids to reduce the risk for infection (2.) correct— urine should be strained to collect any stones that may be passed so that they can be analyzed for composition; after this procedure reveals no stones, more sophisticated or expensive procedures are implemented (3.) part of neurological assessment and not appropriate; should give priority to response to analgesia, hematuria, amount of urinary output, and assess for bladder distention (4.) routine specimen will be analyzed; no need for further specimen collection; primary focus is to obtain stone for analysis

The LPN/LVN admits to the hospital a middle-aged man with terminal lung cancer. His wife states he did not want to come to the hospital and has no desire to "slow down." The LPN/LVN should give priority to which of the following measures? 1. Encourage the client to participate in planning his own care. 2. Set limits on the client's excessive activities. 3. Encourage the client to accept help from others. 4. Promote rest and relaxation for the client.

Strategy: Determine the outcome of each answer. Is it the priority? (1) CORRECT—this client obviously thrives on independence; would be most helpful to support his desire for a sense of control over his care; give choices wherever possible, and allow self-care when feasible (2) encourage clients to be independent; this client is apparently able to make proper decisions (3) provide opportunities for client to participate in decision-making (4) if that is what the client desires

The LPN/LVN assists in the teaching of a client recently diagnosed with type 1 diabetes about proper meal planning. Which of the following actions should the LPN/LVN have taken FIRST? 1. Instruct the client about the importance of eating regular meals. 2. Inform the client that 50 to 60% of calories should come from carbohydrates. 3. Obtain a diet history that includes the client's favorite foods and usual meals. 4. Teach the client how to use the Exchange List for Meal Planning.

Strategy: Gather data before implementing. (1.) implementation; if client is on conventional insulin regimen (one or two injections per day), important to eat regular meals to cover the peak time of the insulin (2.) implementation; caloric distribution for diabetic diet of 50 to 60% carbohydrates, 20 to 30% fat, and 10 to 20% protein (3.) CORRECT — assessment; before beginning teaching, should obtain a thorough diet history and obtain client's weight and determine whether there is a need for weight loss, weight gain, or weight maintenance; goal of diet is for client to maintain a reasonable body weight and control blood glucose; client more likely to make the lifestyle changes required (4.) implementation; appropriate after assessment is completed

The LPN/LVN cares for clients on the medical/surgical floor. The LPN/LVN determines assignments are appropriate if the nurse assigns the LPN/LVN to which of the following clients? 1. A client receiving tissue plasminogen activator (tPA). 2. A client diagnosed with Raynaud's disease who had a sympathectomy. 3. A client admitted in sickling crisis. 4. A client diagnosed with dysrhythmia who had a permanent pacemaker implanted.

Strategy: LPN/LVN cares for stable client with expected outcomes. (1.) thrombolytic given to treat embolism; side effects include anaphylaxis, spontaneous bleeding, and dysrhythmias; client is not stable (2.) CORRECT — Raynaud's disease is a form of intermittent arteriolar vasoconstriction; sympathectomy interrupts the sympathetic nerves; stable client with an expected outcome (3.) unstable client (4.) assess client's cardiac output and hemodynamic stability to evaluate the success of the pacemaker

The nursing team consists of an RN, one LPN/LVN and two nursing assistants. The LPN/LVN should question which of the following client assignments? 1. The RN assigns the LPN/LVN to care for a client in Buck's traction. 2. The RN assigns the LPN/LVN to administer digoxin (Lanoxin) and furosemide (Lasix) via an NG tube. 3. The RN assigns the LPN/LVN to care for a client 48 hours after a hip replacement. 4. The RN assigns the LPN/LVN to care for a client 12 hours after a laminectomy with spinal fusion who is having difficulty voiding.

Strategy: LPN/LVN cares for stable clients with expected outcomes. (1.) appropriate client for the LPN/LVN; stable client with expected outcome (2.) appropriate assignment for the LPN (3.) appropriate assignment for the LPN (4.) CORRECT— unstable patient, requires skills of RN

The LPN/LVN identifies which of the following nursing goals has HIGHEST priority when caring for a client with a history of seizures? 1. Prevent the occurrence of fractures. 2. (2)Protect the head and neck from injury. 3. Provide adequate emotional support. 4. Protect from physical exposure or social bias.

Strategy: Physical needs take priority over psychosocial needs. (1) fractures can occur during attempts at restraint or if the client falls and strikes the head, the trunk, or the limbs against firm objects (2) CORRECT—during a seizure, the nursing objective is to prevent injury (3) seizures occur during reduced level of consciousness in which clients are unable to protect themselves physically; the LPN/LVN provides the needed protection; emotional support is needed to deal with the social issues often imposed on clients with a history of seizures (4) while the LPN/LVN should cover the client during a seizure and shield from curiosity seekers, the first priority includes airway protection or protection from injury

A client is admitted to the hospital with symptoms of myasthenia gravis. When caring for this client, the LPN/LVN should give FIRST PRIORITY to which of the following nursing goals? 1. Provide meticulous personal hygiene. 2. Maintain balance between activity and rest. 3. Maintain respiratory function. 4. Promote adequate hydration.

Strategy: Remember ABCs. (1) usually unable to perform ADLs and will need assistance (2) prevents excessive fatigue and assures high quality of life; maintaining respiratory function takes priority (3) CORRECT—affects respiratory muscles resulting in risk for hypoxia; also affects facial muscles together with laryngeal function; maintaining oxygenation and prevention of aspiration should be given highest priority (4) because swallowing may be a problem, hydration may be an issue; oxygenation takes priority

The LPN/LVN comes on a multi-vehicle accident on the freeway. Which of the following accident victims should the LPN/LVN see FIRST? 1. A client with a 2-inch-long scalp laceration. 2. A client with clear fluid draining from the right ear. 3. A client with a hematoma on the forehead. 4. A client whose pupils are equal and reactive to light.

Strategy: Select the most unstable client. (1) unless is bleeding profusely, tending to client can be delayed (2) CORRECT—clear fluid from the ears could be a sign of a basilar skull fracture; should be suspicious of leaking cerebrospinal fluid, which is indicative of a serious head injury (3) could indicate a possible head injury; draining clear liquid could indicate the ventricles have been penetrated and takes priority (4) normal finding

After reviewing the records of a client diagnosed with cirrhosis, the LPN/LVN should report which of the following lab values to the supervising nurse? 1. Serum albumin 4.0 g/dL. 2. Serum aspartate aminotransferase (AST, SGOT) 38 units. 3. Serum alanine aminotransaminase (ALT, SGPT) 600 units. 4. Serum lactate dehydrogenase (LDH) 150 units.

Strategy: Think about each answer. (1) albumin synthesis depends on normal liver function; normal is 3.5-5.5 g/dL; decreased in liver disease (2) enzymes that are released from liver due to damaged cells; elevated in liver damage; normal is 10-40 U/L (3) CORRECT—elevation indicates serious liver damage; normal is 5-35 units (4) LDH elevated in liver disease; normal is 100-190 units

Because of specific physiological changes in clients with cirrhosis, the home care LPN/LVN teaches the family that the client should include the following nutrients in the daily diet? 1. Increased calories and decreased vitamins. 2. Increased protein and increased carbohydrates. 3. Increased calcium and decreased fat. 4. Increased iron and decreased salt.

Strategy: Think about each answer. (1) diet therapy includes increased protein, calories, and vitamins (2) CORRECT—because many alcoholics are malnourished, a high-protein diet is important (3) no change in calcium; moderate amounts of fat allowed (4) may require low-sodium diet if client has ascites; no change in iron requirements

The LPN/LVN participates in the preoperative instruction of a client scheduled for a colostomy. The LPN/LVN instructs the client that 24 hours after surgery the colostomy drainage will MOST likely look like which of the following? 1. There will be a large amount of bloody output. 2. There will be a large amount of liquid stool. 3. There will be formed stool with water. 4. There will be a scant amount of bright bloody drainage.

Strategy: Think about each answer. (1) excessive amount of bleeding is not expected; most of drainage should be serous sanguineous; colostomy should start to function two to four days postop (2) ingestion of foodstuffs must precede fecal production; after colostomy begins functioning, initial stool will be liquid; if colostomy in ascending colon, stool will always be liquid (3) formed stool present from a colostomy in the descending colon; takes two to four days after client begins eating for colostomy to begin functioning due to decompression and bowel cleansing that takes place prior to surgery (4) CORRECT—small amount of bleeding at stoma expected; report excessive amounts of bleeding

The LPN/LVN selects which of the following nursing goals as MOST realistic and appropriate when implementing care for a client with Parkinson's disease? 1. Return the client to usual activities of daily living. 2. Maintain optimal function within the client's limitations. 3. Prepare the client for a peaceful and dignified death. 4. Arrest progression of the disease process.

Strategy: Think about each answer. (1) is progressive disease (2) CORRECT—Parkinson's is an irreversible disease that leads to permanent physical limitations; it is most appropriate and realistic to assist the client to maintain optimal functioning within the limitations of the disease process (3) client's health eventually declines and death becomes imminent; because clients live many years before death occurs, is not the most appropriate (4) goal of therapeutic interventions is to help client manage impairments imposed by the disease as the process progresses; medications eventually become ineffective

When witnessing the client's signing of an informed consent form, it is MOST important for the LPN/LVN to make which of the following assessments? 1. Does the client understand the procedure? 2. Does the client have any questions? 3. Does the client give consent voluntarily? 4. Is the client able to write his name?

Strategy: Think about each answer. (1)it is the physician's responsibility to explain the procedure and the risks and benefits associated with the procedure (2)should not obtain the signature if client has questions LPN/LVN cannot or is not authorized to answer (3)CORRECT—LPN/LVN's signature indicates that the client voluntarily gave consent, the client's signature is authentic, and the client indicates an understanding of what is being signed (4)client legally able to place mark on consent form or write out name

A client is admitted to the hospital with a white blood cell count of 1,500/mm3. When caring for the client, the LPN/LVN should consider which of the following nursing diagnoses as the highest priority? 1. Ineffectual individual coping. 2. Fatigue. 3. Self-care deficit. 4. Risk for infection.

Strategy: Think about each answer. (1)physical needs take priority over psychosocial needs (2)may be fatigued due to bone marrow depression, but no information is given to support this nursing diagnosis (3)no data given to support this nursing diagnosis (4)CORRECT—client's white blood cell count is far below range of 5,000 to 10,000/mm3, placing him/her at high risk for developing a life-threatening infection

A patient is admitted with a cerebrovascular accident (CVA). The nurse notes that the patient has difficulty swallowing and requires assistance with bathing, toileting, and feeding. The delegation is appropriate if the RN delegates the tasks of bathing and toileting to which of the following staff members? 1. The nursing assistant. 2. The LPN/LVN. 3. The RN. 4. The clinical nurse specialist.

Strategy: Think about each answer. (1.) CORRECT— assist with direct patient care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height and weight, intake and output, housekeeping, transporting stable patients, and stocking supplies; appropriate delegation (2.) assist with implementation of care, perform procedures, differentiate normal from abnormal, care for stable patients with predictable outcomes, has knowledge of asepsis and dressing changes and may administer medications which vary with educational background and state nurse practice acts (3.) the RN can never delegate patients who require assessment, teaching, or nursing judgment; when delegating to UAPs, the nurse should evaluate the activities being considered for delegation; five factors affecting the decision to delegate are potential for harm to the patient, complexity of the nursing activity, extent of problem solving, predictability of outcome, and extent of interaction (4.) advanced practice nurse has a master's degree and advanced education and expertise in specialized areas of nursing

The nursing team consists of two RNs, two LPN/LVNs, and two patient care technicians. The LPN/LVN determines that delegation is appropriate if the LPN/LVN is assigned which of the following? 1. Perform a sterile dressing change. 2. Obtain vital signs. 3. Stock supplies of syringes and dressings. 4. Transfer a stable patient to x-ray.

Strategy: Think about each answer. (1.) CORRECT— assist with implementation of care, perform procedures, differentiate normal from abnormal, care for stable patients with predictable outcomes, has knowledge of asepsis and dressing changes, and may administer medications which vary with educational background and state nurse practice acts (2.) appropriate activity for nursing assistants; assist with direct patient care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height and weight, intake and output, housekeeping, transporting stable patients, and stocking supplies (3.) appropriate activity for nursing assistants; assist with direct patient care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height and weight, intake and output, housekeeping, transporting stable patients, and stocking supplies (4.) appropriate activity for a nursing assistant; assist with direct patient care activities such as bathing, transferring, ambulating, feeding, toileting, obtaining vital signs, height and weight, intake and output, housekeeping, transporting stable patients, and stocking supplies

A nursing assistant caring for clients in the long-term care facility collapses minutes after putting on latex gloves. The assistant is successfully resuscitated. After reviewing the medical histories of the staff in the long-term care facility, the LPN/LVN determines which of the following staff members can safely use latex products? 1. The staff member with a history of allergies to pollen and grass. 2. The staff member with a history of allergies to banana and kiwi. 3. The staff member with a history of multiple surgeries. 4. The staff member with a history of GI upset.

Strategy: Think about each answer. (1.) at risk for latex allergies; incidence of latex allergies has increased since the advent of universal precautions; latex found in gloves, goggles, blood pressure cuffs, stethoscopes, oral and nasal airways, and IV tubing; OSHA states that employers have responsibility to inform health care workers about potentially dangerous substances in the workplace (2.) at greater risk for latex allergies (3.) at greater risk for latex allergies (4.) CORRECT— does not cause nurse to be at risk for latex allergies

The LPN/LVN cares for a conscious client diagnosed with severe ketoacidosis. The LPN/LVN is MOST likely to administer which of the following? 1. Orange juice. 2. Peanut butter. 3. Regular insulin. 4. NPH insulin.

Strategy: Think about each answer. (1.) increases blood sugar; appropriate action for insulin reaction (2.) commonly administered for hypoglycemia together with a natural glucose source to prevent rebound hypoglycemia (3.) CORRECT— because regular insulin has a rapid onset and can be administered intravenously, it is the main therapeutic measure in the treatment of diabetic ketoacidosis (4.) because NPH has an onset of 6 to 8 hours, it does not match the urgency of the client's need; even if it could be administered intravenously, the onset would not meet the needs of a client with severe ketoacidosis

The supervising nurse discusses substance abuse among the nursing staff. Which of the following behaviors, if demonstrated by a staff member, should cause the LPN/LVN to alert the supervising nurse about a potential problem with substance abuse? 1. A staff member changes hair color frequently. 2. A staff member appears quiet in group meetings. 3. A staff member frequently arrives early for work. 4. A staff member does not allow another nurse to sign that narcotics are wasted.

Strategy: Think about each answer. (1.) may see a major change in appearance, such as poor hygiene and appearing disheveled (2.) behavior will be erratic and there will be frequent changes in mood (3.) will be very late for work or will not show up (4.) CORRECT— impaired nurse might forge another RN's signature and then consume the narcotic that was not wasted; will also see unprofessional conduct, frequent complaints of pain by patients during the impaired nurse's care

The nursing team consists of two RNs, one LPN/LVN, and two nursing assistants. The LPN/LVN should consider the assignment appropriate if the RN assigns which of the following to the LPN/LVN? 1. Obtain vital signs for a patient immediately after ECT. 2. Assist a patient with bathing and feeding. 3. Administer a tube feeding for a patient with dysphagia. 4. Discharge a patient diagnosed with multiple sclerosis.

Strategy: Think about each answer. (1.) requires assessment of the RN; immediately after procedure, orient patient, take blood pressure and respirations, stay with patient during times of confusion; nursing assistant can obtain vital signs after patient alert and oriented (2.) appropriate assignment for the nursing assistant; assign standard, unchanging procedures (3.) CORRECT— assign stable patients with expected outcomes (4.) appropriate activity for the RN; the RN cannot delegate assessment, teaching, or nursing judgment