LVN 3
A client with a history of heart disease is given a prescription for 4 grains of aspirin which comes in 81 mg per tablet. The client asks the nurse, "how many tablets should I take?" What is the nurse's best response? Round to the nearest whole number.
3 tablets 4 grains x 60 mg = 240 mg/81 mg = 2.96=3 tabs
The nurse is assessing the psychosocial status of a postpartum client. Which statement indicates that the mother is likely to have a successful parent-neonate attachment? a) "My previous experience was so awesome!" b) "I want to lie skin to skin with my baby for as long as possible after delivery." c) "Bonding is important to my baby's development." d) "I want to bond with my baby right away."
b) "I want to lie skin to skin with my baby for as long as possible after delivery." Reason: Sustained parent-neonate contact immediately after delivery is most likely to promote parent-neonate attachment. The first period of neonatal reactivity, which occurs during the first hour after delivery, is the ideal time for behavior that promotes attachment, such as touching, holding, talking, examining, and breast-feeding. Although parental desire to bond and understanding of the importance of bonding can contribute to parent-neonate attachment, early contact is a prerequisite. A previous positive childbirth experience may enhance parent-neonate attachment but is less crucial than sustained contact immediately after delivery
The nurse is caring for a client who underwent internal fixation of the right hip. Before administering the client's warfarin, the nurse checks the laboratory report for the client's International Normalized Ratio (INR) results. Which of the following indicates the therapeutic range for this client? a) 1.0 to 2.0 b) 2.0 to 3.0 c) 1.5 to 2.0 d) 3.0 to 4.0
b) 2.0 to 3.0 Reason: Recent guidelines recommend an INR of 2.0 to 3.0 for clients without mechanical prosthetic heart valves who are receiving warfarin therapy. For clients with mechanical prosthetic heart valves, an INR of 2.5 to 3.5 is suggested. An INR below 2.0 is subtherapeutic with warfarin therapy. An INR above 3.0 in a client without a prosthetic valve indicates the need to reduce the warfarin dose.
A client had a laxative prescribed that acts by causing stool to absorb water and swell. Which term describes this type of laxative? a) Emollient b) Bulk-forming c) Stimulant d) Lubricant
b) Bulk-forming Reason: Bulk-forming laxatives cause stool to absorb water and swell. Emollients lubricate stool; lubricants soften stool, making it easier to pass. Stimulants promote peristalsis by irritating the intestinal mucosa or stimulating nerve endings in the intestinal wall
A nurse is caring for a client with multiple myeloma. What is a sign that a client with multiple myeloma isn't coping well with his prognosis? a) He shows concern about his family during his treatment. b) He avoids any conversation concerning his health. c) He becomes tearful when discussing his condition. d) He asks questions about his prognosis.
b) He avoids any conversation concerning his health. Reason: A client with multiple myeloma who avoids conversation may be denying his condition, which can interfere with treatment. Crying is a normal response to his disease. Asking questions about his prognosis is a normal coping response, as is showing concern for his family.
The infection control nurse is making rounds to ensure that airborne precautions are being observed while caring for clients with tuberculosis. Which action by the staff nurse requires further education? a) The nurse double-bags respiratory secretions. b) The nurse dons a surgical isolation mask when entering the client's room. c) The client's meals are served on disposable trays. d) The nurse gathers disposable client care items.
b) The nurse dons a surgical isolation mask when entering the client's room. Reason: When entering the room of a client with tuberculosis, the nurse should wear an N95 particulate respirator mask because surgical isolation masks allow turbide bacilli to pass through. All trash and waste should be disposed of as infectious waste. All client care items and meal trays should be disposable
A geriatric client has experienced several adverse drug reactions. What does the nurse recognize that this client may benefit from? a) Increased drug doses at longer intervals b) Frequent visits to the physician c) Reduced drug dosages d) Nursing home placement
c) Reduced drug dosages Reason: Older clients commonly have diminished hepatic and renal function that reduces drug metabolism and excretion. Adverse reactions tend to be related to blood level; therefore, the client may benefit from reduced drug dosages. Adverse drug reactions aren't a cause for nursing home placement. Increased drug doses at longer intervals may increase adverse reactions rather than decrease them. Although frequent visits to the physician may benefit the client, the visits themselves won't alter how the drug reacts in the client's body.
A student nurse is preparing a care plan using the nursing diagnosis: risk for situational low self-esteem related to intervention by social services as evidenced by poor eye contact, flat affect, and behavioral changes for a child entering the foster care system. Which action(s) by the foster parents indicate that the teaching interventions to improve self-esteem were successful? Select all that apply. a) The parents established a critical environment for behavior to enhance situational understanding. b) The parents sought opportunities to provide honest praise. c) The parents used physical discipline when necessary to reinforce rules. d) The parents developed a written plan describing consistent limits on good and bad behavior. e) The parents maintained inconsistent boundaries to challenge decision-making.
b) The parents sought opportunities to provide honest praise. d) The parents developed a written plan describing consistent limits on good and bad behavior. Reason: Teaching interventions are successful as demonstrated by the following answer choices: a structured lifestyle with consistent limits demonstrates acceptance and caring and provides a sense of security, and honest praise for good behavior promotes self-esteem. On the other hand, a critical environment erodes a person's esteem; inconsistent boundaries lead to feelings of insecurity and lack of concern; and physical discipline and false praise can decrease one's self-esteem.
The nurse is trying to establish rapport with a newly admitted client. Which statements will facilitate effective communication? Select all that apply. a) "Why are you crying?" b) "Tell me about your treatment so far." c) "What did your physician tell you about your need for hospitalization?" d) "Everything will be all right." e) "Did you take your medicine yesterday?"
c) "What did your physician tell you about your need for hospitalization?" b) "Tell me about your treatment so far Reason: Giving advice, providing false reassurance, and asking the client why he or she is crying is judgmental, all of which block rather than promote effective communication with a client. Asking open-ended questions and using leading questions promote effective communication
The nurse educator is presenting an in-service on pediatric assessments. Why should the educator instruct nursing staff to inspect first and then auscultate when collecting data on a pediatric clients? a) Because the nurse's touch may frighten the child b) Because the nurse's hand or stethoscope may feel cold, making the child recoil c) Because the child may cry as data collection proceeds, making auscultation difficult d) Because the nurse's touch may calm the child
c) Because the child may cry as data collection proceeds, making auscultation difficult Reason: Because other data collection procedures may make the child cry, the nurse should auscultate the child's lungs immediately after inspection. Crying increases the respiratory rate and creates noise that interferes with clear auscultation
A nurse is caring for a client who was admitted to the emergency department after a motor vehicle collision. Under the law, informed consent before treatment must be obtained unless which circumstance exists? a) The client asks the nurse to give substituted consent. b) The client refuses to give informed consent. c) The client is in an emergency situation. d) The client is mentally ill.
c) The client is in an emergency situation. Reason: The law doesn't require informed consent in an emergency situation when the client is unable to give consent and no next of kin is present. A mentally competent client may refuse or revoke consent at any time. The client may also refuse treatment. Even though a client who has been declared mentally incompetent can't give informed consent, mental illness doesn't by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent.
The nurse prepares to measure a client's blood pressure. What correct procedure for measuring blood pressure would the nurse utilize? a) Wrapping the cuff around the limb, with the uninflated bladder covering about one-fourth of the limb circumference b) Using a bladder that is 6" (15 cm) long c) Wrapping the cuff around the limb, with the uninflated bladder covering about three-fourths of the limb circumference d) Measuring the arm about 2" (5 cm) above the antecubital space
c) Wrapping the cuff around the limb, with the uninflated bladder covering about three-fourths of the limb circumference Reason: When measuring blood pressure, the nurse should place the cuff 1" (2.5 cm) above the brachial pulse and then wrap the cuff around the client's arm or leg with the bladder uninflated; the bladder should cover approximately three-fourths (not one-fourth) of the limb circumference. Bladder size is chosen according to the size of the extremity.
A client begins taking haloperidol. After a few days, he experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as: a) akathisia. b) psychotic symptoms. c) dystonia. d) parkinsonism.
c) dystonia Reason: These symptoms describe dystonia, which commonly occurs after a few days of treatment with haloperidol. The symptoms may be confused with psychotic symptoms and misdiagnosed. Parkinsonism results in muscle rigidity, shuffling gait, stooped posture, flat-faced affect, tremors, and drooling. Signs and symptoms of akathisia are restlessness, pacing, and inability to sit still
A first-term nursing student is preparing to use a stethoscope to auscultate a client's chest. The nursing instructor asks the student to explain the working of the stethoscope. Which statement, provided by the student, about a stethoscope with a bell and diaphragm is true? a) "The diaphragm detects low-pitched sounds best." b) "The bell detects high-pitched sounds best." c) "The bell detects thrills best." d) "The diaphragm detects high-pitched sounds best."
d) "The diaphragm detects high-pitched sounds best." Reason: The diaphragm of a stethoscope detects high-pitched sounds best; the bell detects low-pitched sounds best. Palpation detects thrills best.
The nurse is collecting data on a client who appears to miss portions of what is being asked by the nurse. The client's family member tells the nurse that the client has a hearing aid, but will not wear it. The client states, "It worked when I first got it, but now it's a nuisance because I can't hear anything with it." The nurse asks which question to gain a better understanding of the client's concern? a) "Have you notified the medical equipment place where you got the hearing aid?" b) "Let's look at having your hearing aid refitted." c) "You have not given it a chance to work. You must wear it all the time." d) "Have you checked the battery to make sure it works?"
d) "Have you checked the battery to make sure it works?" Reason: The client stated the hearing aid no longer works, so the nurse needs to determine if there is a problem; asking about the battery is appropriate. Before contacting the medical equipment company, the client should check the battery first. Even if the hearing aid is ill-fitted, it still should work, so the battery needs to be checked. The hearing aid was working, so the client did give it an opportunity to work.
A client with nephritis is taking the diuretic furosemide as prescribed. Which client statement indicates an accurate understanding of teaching about furosemide? a) "I'll avoid consuming magnesium-rich foods." b) "I'll take furosemide at night so it works first thing in the morning." c) "I'll watch for and report signs of hypercalcemia." d) "I'll eat such foods as apricots, dates, and citrus fruits."
d) "I'll eat such foods as apricots, dates, and citrus fruits." Reason: Because furosemide is a potassium-wasting diuretic, the client should eat potassium-rich foods, such as apricots, dates, and citrus fruits, to prevent potassium depletion. The client may also consume magnesium-rich foods as desired. The client should watch for signs of adverse reactions to furosemide, such as hypocalcemia (not hypercalcemia). If furosemide is prescribed once daily, it should be taken in the morning; taking the medication at night causes frequent awakening because of the need to urinate
A 57-year-old client reports experiencing leg pain whenever he walks several blocks. The client has type 1 diabetes and has smoked two packs of cigarettes per day for the past 40 years. The physician diagnoses intermittent claudication. The nurse should provide which instruction about long-term care to the client? a) "See the physician if the symptoms bother you." b) "Consider cutting down on your smoking." c) "Reduce your exercise level." d) "Practice meticulous foot care."
d) "Practice meticulous foot care." Reason: Intermittent claudication and other chronic peripheral vascular diseases reduce oxygenation to the feet, making them susceptible to injury and poor healing; therefore, meticulous foot care is essential. The nurse should teach the client to bathe his feet in warm water, dry them thoroughly, cut his toenails straight across, wear well-fitting shoes, and avoid taking medication unless cleared by the physician. The client should stop smoking, not just cut down, because nicotine is a vasoconstrictor. Daily walking benefits the client with intermittent claudication. The client should see the physician regularly, not just when he's bothered by symptoms
What elements must be proven by a client's attorney in the case of a professional negligence action? a) Duty, breach of duty, and damages b) Duty, damages, and causation c) Breach of duty, damages, and causation d) Duty, breach of duty, damages, and causation
d) Duty, breach of duty, damages, and causation Reason: Any professional negligence action must meet certain demands in order to be considered negligence and result in legal action. They're commonly known as the four D's: duty of the health care professional to provide care to the person making the claim, a dereliction (breach) of that duty, damages resulting from that breach of duty, and evidence that damages were directly due to negligence (causation)
A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which nursing intervention is appropriate for this client? a) Invite the client's clergyman to visit. b) Avoid discussions about religious beliefs and practices. c) Ignore the client's spiritual distress. d) Encourage the client to discuss concerns with a clergy member.
d) Encourage the client to discuss concerns with a clergy member. Reason: Encouraging the client who is spiritually distressed following cancer surgery to discuss his concerns with a clergy member is an appropriate intervention. The nurse should also encourage the client to discuss his religious beliefs and practices. Ignoring the client's spiritual distress doesn't build a therapeutic relationship with the client. The nurse shouldn't invite a clergyman to visit the client, unless the client specifically asks to see that member of the clergy
The nurse is caring for a client with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? a) Measure blood urea nitrogen and serum creatinine levels. b) Measure intake and output. c) Monitor vital signs every 4 hours. d) Monitor the appearance, size, and number of stools.
d) Monitor the appearance, size, and number of stools. Reason: When a client with celiac disease is placed on a gluten-free diet, fat, bulky, foul-smelling stools should be eliminated. This indicates that the disease is controlled and the client is using nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't provide an indication of the effectiveness of diet therapy
