LVN NCLEX 5

A 68-year-old client with end-stage chronic obstructive pulmonary disease (COPD) has discharge orders that include home oxygen therapy. The client exhibits anxiety about becoming dependent on supplemental oxygen. How can a nurse help allay the client's anxiety?

Remain with the client during an education session taught by the respiratory therapist, and reinforce teaching after the session.

An older adult client has been admitted to the medical-surgical unit after surgery. While the nurse is off the floor, the client falls out of bed, resulting in a fracture of the right leg. The nurse finding the client states that the "side rails were left down and the bed was in the high position." Which charge is most appropriate for the nurse's actions? comparative negligence battery collective liability negligence

negligence

A clinical pathway is guiding care for a postpartum client who had an uncomplicated vaginal delivery of an 8-lb, 2-oz (3,686-g) baby 24 hours ago. The client has no episiotomy and is bottle-feeding her baby. Which outcome should be achieved within the next 8 hours?

Client will demonstrate ability to bottle-feed the neonate.

The nurse is aware that Standard Precautions represent the first tier of Centers for Disease Control guidelines for isolation precautions. Which is the nurse's primary responsibility when following Standard Precautions?

Consider all body substances potentially infectious

After undergoing a right lower lobectomy for treatment of lung cancer, a 75-year-old client returns to his room with a chest tube in place. Several hours later a nurse finds the client out of bed barely able to speak, with the chest tube removed. Which action should the nurse take immediately?

Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client.

The parents of a pediatric client are waiting in the surgical family lounge while their son undergoes emergency surgery. A physician enters the family lounge and tells another family that surgery for their family member was unsuccessful. What should the nurse do to best serve these families? Escort the parents who are waiting to hear about their son to another area. Escort the family who received the discouraging news to a private area. Ask the physician to inquire about the progress of the pediatric client's surgery. Do nothing.

Escort the family who received the discouraging news to a private area.

The nurse educator is presenting information about Standard Precautions to a group of newly hired nurses. Hand hygiene is a necessity in Standard Precautions. Which true statement about hand washing would the educator include in her teachings?

Frequent hand washing reduces transmission of pathogens from one client to another.

A female client has a fractured left hip. Her left leg is in Buck's traction while the client is being prepared for a hip pinning. What should the nurse plan to do when inserting an indwelling catheter? Choose a No. 12 French catheter. Instruct the client to deep breathe during catheterization. Add tape to the catheter tray for taping the indwelling catheter to the client's abdomen. Instruct the client to turn on her right side with both legs flexed.

Instruct the client to deep breathe during catheterization.

A client recovering from back surgery tells a nurse that she's concerned about going home. She explains that she has many stairs to navigate and household responsibilities she must perform. How can the nurse help ease this client's concerns?

Notify the charge nurse of the client's concerns, and request a team meeting to discuss the client's discharge planning.

A nurse discovers that a stat dose of potassium chloride that was prescribed by the physician was never administered. Which action should the nurse take?

Notify the charge nurse so she can notify the physician of the missed dose.

A nurse is caring for a client who received pain medication before leaving the post anesthesia care unit (PACU). Upon returning to the room, the client reports pain and requests more pain medication. Which action is most appropriate for the nurse to take?

Obtain the client's vital signs.

A nurse monitors members of the healthcare team for the use of interventions to reduce the occurrence of methicillin-resistant staphylococcus aureus (MRSA) and other nosocomial infections. Which finding demonstrates to the nurse that the team members understand infection control measures?

Performing hand hygiene before and after contact with every client

The physician orders contact precautions for a client with a draining wound. Which action should the nurse take to initiate these precautions?

Place an isolation cart containing gloves and gowns outside the client's room.

After a physician explains the risks and benefits of a clinical trial to a client, the client agrees to participate. Later that day, the client requests clarification of the process involved in the clinical trial. As a member of the multidisciplinary team, how should the nurse respond?

Provide the information requested

Four clients on an orthopedic unit are scheduled to attend physical therapy at the same time. Facility policy dictates that each client be escorted to therapy in a wheelchair or on a stretcher. When it's time for therapy, only three wheelchairs are available. One of the four clients is learning crutch-walking and is scheduled for discharge in the morning. What should the nurse do to ensure the clients' safety and timely arrival to physical therapy?

Request that a physical therapist accompany the client to therapy while he uses the crutches.

no redness noted." "Client up in chair three times today." "Improved skin turgor noted." When creating the nursing care plan, which diagnosis would the nurse select to accurately reflect this information? Constipation related to immobility Impaired skin integrity related to immobility Risk for impaired skin integrity related to immobility Disturbed body image related to immobility

Risk for impaired skin integrity related to immobility

After completing a course on infection control, a licensed practical nurse (LPN) demonstrates knowledge of the use of standard precautions based on which statement?

Standard precautions are mandatory for use with all client care.

A nurse is reviewing infection-control measures with a group of unlicensed assistive personnel (UAP). Which statement made by one of the group members indicates learning goals have been met?

Standard precautions should be used when performing client care.

A nurse caring for a client with acquired immunodeficiency syndrome (AIDS) is working with a nursing student. The student does not attempt to suction or assist with care of the client. Which action by the nurse is appropriate?

Talk to the student to determine the issue.

The nurse suspects that a client is not swallowing the administered dose of an anxiolytic medication and is concerned that the client may be disposing of it in the trash. Which action should the nurse take first?

Talk with the client about the concerns.

A nurse is caring for a client with end-stage testicular cancer who has been referred to hospice care. Which criterion excludes the client from hospice care?

The client entered a clinical trial through the National Cancer Institute.

A nurse is assigned to care for a client in the immediate postoperative recovery phase. Which data collection takes priority during the initial assessment? vital signs, presence of reflexes, and intake and output airway, respiratory rate and depth, other vital signs, and skin color dressings, drains, and intake and output level of consciousness and presence of reflexes

airway, respiratory rate and depth, other vital signs, and skin color

Which finding is common when gathering data from a child with a total anomalous pulmonary venous return defect?

frequent respiratory infections

The nurse reinforces the client's teaching on a low-sodium diet. Which statement by the client indicates that the nurse's nutritional instruction has been effective? "I chose a baked potato with broiled chicken for dinner." "I chose chicken bouillon soup for lunch every day." "I chose a tossed salad with sardines and oil and vinegar dressing for lunch." "I can still eat a ham-and-cheese sandwich with potato chips for lunch."

"I chose a baked potato with broiled chicken for dinner."

A nurse is reviewing prenatal care with a client. Which statement by the client best expresses an adequate understanding of the nutritional needs during pregnancy? "Even though I need to eat more, I should make sure I don't fill up with junk food." "After gaining a few pounds each month, I'll really get big and put on 20 pounds or so." "I guess I'll get big and gain 20 to 30 pounds and look pregnant." "Since I have to eat for two, I should eat whatever I want whenever I feel hungry."

"Even though I need to eat more, I should make sure I don't fill up with junk food."

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. Which condition would benefit from hyperbaric oxygen therapy?

compromised skin graft

A nurse is caring for a client who's taking the anticoagulant warfarin (Coumadin). Which instruction regarding warfarin therapy should the nurse give to the client? Use a straight razor when shaving. Limit foods high in vitamin K. Report incidents of diarrhea. Take aspirin for pain relief.

Limit foods high in vitamin K.

The nurse preceptor is discussing Standard Precautions with a graduate nurse. The preceptor should include which measures when discussing Standard Precautions? Select all that apply.

>wear gloves when administering intramuscular (IM) medication >wash hands after removal of gloves

The nurse is reviewing a client's plan of care. The following statement appears on the client's plan of care: "Client will ambulate in the hall without assistance within 4 days." What does the nurse recognize this statement as an example of? Subjective data A nursing intervention A client outcome A nursing diagnosis

A client outcome

Which statement by a client demonstrates to the nurse that the client understands the best time to perform a self-breast exam?

"I'll examine my breasts a week after my menstrual period starts."

A newly hired graduate nurse asks her preceptor, "What is a common goal of discharge planning in all care settings?" How does the preceptor correctly respond?

"The goal is teaching the client how to perform self-care activities."

During a private conversation, a client with borderline personality disorder asks the nurse to keep his secret and then displays multiple, self-inflicted, superficial lacerations on his forearms. What is the most appropriate way for the nurse to respond?

"The team needs to know when something important occurs in treatment. I need to tell the others, but let's talk about it first."

The nurse assesses capillary refill in a client admitted with pneumonia and dehydration. Which capillary refill duration is considered abnormal and should be reported? 1 second 4 seconds 3 seconds 2 seconds

4 seconds

A nurse is caring for a client who is 6 hours postpartum. The nurse observes a moderate amount of blood clots in the pad, a boggy uterus, and blood pressure of 90/60 mmHg. Which actions should the nurse take? Select all that apply.

>Massage the fundus. >Notify the health care provider. > Give prescribed Methergine. >Ask the client to empty her bladder.

The nurse just received the shift report on her group of clients. Based on the information she received, which client should she assess first?

A client who underwent a right nephrectomy yesterday and is complaining of pain

Which intervention does the nurse educator include in his or her preparation as an example of primary prevention? Using occupational therapy to help a client cope with arthritis Obtaining a Papanicolaou (PAP) test to screen for cervical cancer Administering digoxin to a client with heart failure Administering a measles, mumps, and rubella immunization to an infant

Administering a measles, mumps, and rubella immunization to an infant

The charge nurse is making client care assignments. Which client is most appropriate for a licensed practical nurse?

A stable 6-month-old infant with pneumonia

A client arrives in the emergency department reporting squeezing, substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What nursing action is a priority?

Administer O2, attach a cardiac monitor, take vital signs, and administer aspirin and sublingual nitroglycerin.

A client with end-stage pulmonary hypertension tells his physician that he doesn't want any heroic measures should his heart stop and that he doesn't want to be placed on a ventilator. The physician enters a do-not-resuscitate order into the hospital's computer system. Which ethical principle is a nurse upholding by supporting the client's decision?

Autonomy

A nurse is working with the team to develop a neonate's plan of care. Which action would be the highest priority in regulating the neonate's temperature?

Block sources of radiant, convective, conductive, and evaporative losses.

Which nursing action is appropriate when performing wound care for a client who has a diabetic foot ulcer?

Change the sterile field after sterile water is spilled on it

A client suspected of having a pulmonary embolus is scheduled for a lung scan. What is the most important action for the nurse prior to the procedure?

Check all allergies of the client.

A client who returns to the surgical floor after undergoing transurethral resection of the prostate complains of pain. Which action should the nurse take first?

Check the client's medical record for postoperative orders.

The nurse reinforces instructions about how to feed a client with a self-care deficit for the client's family members. Which instruction should the nurse stress to the family? Keep the client on a soft foods or a full liquid diet. Have the health care provider prescribe a gastrostomy tube for feeding the client. Determine which foods the client tolerates best and offer those foods. Ask the health care provider to prescribe parenteral nutrition (PN) for the client.

Determine which foods the client tolerates best and offer those foods.

A nurse is caring for a client who had abdominal surgery 3 days ago. The client states, "I haven't moved my bowels, but I am passing gas." What nursing action is appropriate for this client?

Encourage the client to ambulate.

A nurse is planning care for a client after a tracheotomy. One of the client's goals is to overcome verbal communication impairment. Which nursing intervention should the nurse include when assisting with development of the care plan? Encourage the client to communicate by allowing time to write words. Speak for the client to reduce occurrence of frustration. Avoid using a tracheostomy plug because it blocks the airway. Make an effort to read the client's lips to foster communication.

Encourage the client to communicate by allowing time to write words.

A client in active labor is having difficulty remaining focused. Her husband, sister, and mother are in the room with her. The fetal monitor shows slowing of the fetal heart rate (FHR) that begins after the peak of each contraction. What is the priority nursing action? Let the client get up and walk around the room for several minutes every once and a while. Turn on the television to give the client something on which to gain her focus. Leave the client and the family alone to allow the woman to concentrate on events. Have the client lie on her left side while asking a family member to be with the client one at a time.

Have the client lie on her left side while asking a family member to be with the client one at a time.

After a stroke, a client develops aphasia. The nurse expects to observe which data collection finding in this client? Inability to speak clearly Arm and leg weakness Difficulty swallowing Absence of the gag reflex

Inability to speak clearly

A 33-year-old client who tested positive for the human immunodeficiency virus (HIV) is admitted to the medical unit with pancreatitis. A nurse director from another unit comes into the medical unit nurses' station and begins reading the client's chart. The staff nurse questions the director, who says that the client is her neighbor's son. What should the nurse do to protect the client's right to privacy?

Inform the nurse director that she's violating the client's right to privacy and ask her to return the chart.

A nurse is providing care to a client after surgery. The nurse must practice surgical asepsis when performing which procedure?

Insertion of an indwelling urinary catheter

A 75-year-old client who was admitted to the hospital with a stroke informs the nurse that he doesn't want to be kept alive with machines. He wants to make sure that everyone knows his wishes. Which action should the nurse take?

Make arrangements for the client to receive information about advance directives

A client with a full-term, uncomplicated pregnancy comes into the labor and delivery unit in early labor states, "I think my water has broken." Which action by the nurse would be the priority?

Note the color, amount, and odor of the fluid.

A client newly diagnosed with diabetes mellitus is experiencing difficulty with self-administration of insulin. Despite further teaching, the client shows little improvement. What action by the nurse is most appropriate?

Notify the physician of the client's lack of progress and request a diabetes education department consult.

While being escorted to an operating room, a client is extremely anxious and says, "I really don't know what they're going to do to me today. The physician said I have a lump in my breast and that's all I know." Which action is appropriate for the nurse to take?

Notify the physician upon arrival at the operating room.

A nurse implements standard precautions when caring for a client. Which action best demonstrates proper use of these precautions?

Performing hand hygiene immediately after removing gloves

While driving home from work, a nurse realizes that she failed to communicate to the oncoming nurse that a client asked for more information about advance directives. Which action would be appropriate for the nurse to take? Perform an Internet search on advance directives and provide the client with the information in the morning. Return to work immediately and inform the nurse who is caring for the client. Phone the nurse caring for the client and inform her of the client's request. Provide the client with information when she returns to work in the morning.

Phone the nurse caring for the client and inform her of the client's request.

The nurse is caring for a child with a seizure disorder. Which nursing intervention would be included to support the goal of avoiding injury, respiratory distress, or aspiration during a seizure?

Place a hand under the child's head for support.

A nurse demonstrates how to clean dentures to an unlicensed assistive personnel (UAP). Which action should the nurse make sure to teach the UAP? Scrub the dentures with a cleaning agent and cold water. Put a washcloth in the sink to prevent damage the dentures. Rinse the dentures under hot running water. Clean the dentures over the sink with the drain closed.

Put a washcloth in the sink to prevent damage the dentures.

A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the plan of care?

Putting on an individually fitted N95 respiratory or high-efficiency particulate air (HEPA) respirator when entering the client's room

A client with advanced cancer has been receiving chemotherapy and is experiencing stomatitis. To promote comfort and nutrition while the client's mouth is sore, what should the nurse plan to speak with the client's family about? Brushing the client's teeth with a firm toothbrush Encouraging the client to eat his favorite Mexican foods Pproviding hot fluids, such as tea and broth, between meals Rinsing the client's mouth with diluted hydrogen peroxide every 2 hours

Rinsing the client's mouth with diluted hydrogen peroxide every 2 hours

A physician asks a nurse to witness an informed consent of a client scheduled for gastric bypass surgery. What should the nurse do?

Sign the consent only if she sees the client sign it.

A nurse enters the room of a client who had a left modified mastectomy 8 hours earlier. Which observation indicates that the unlicensed assistive personnel (UAP) assigned to the client needs further instruction and guidance?

The client is wearing a robe with elastic cuffs.

A client undergoes rhinoplasty to repair a nasal fracture. Postoperatively, the client swallows frequently and requires frequent changes of the mustache dressing, which is soiled with bright-red blood. Which is the best action for the licensed practical nurse (LPN) to take?

check the pharynx with a penlight for bleeding, and confer with the registered nurse (RN)

Which information should the nurse include when reinforcing instructions for a client about using vaginal medications? Use a water-soluble lubricant when inserting a suppository. Use a tampon after insertion to increase medication absorption. The suppositories should be kept at room temperature. Release and pull up on the applicator before removal.

Use a water-soluble lubricant when inserting a suppository.

The nurse must administer a liquid medication to an infant. Which step should the nurse take first?

Verify the physician's order.

A nurse working in the triage area of an emergency department sees that several pediatric clients arrive simultaneously. Which child is treated first?

a 2-month-old infant with stridorous breath sounds, sitting up in his or her mother's arms and drooling

Which of the following clients should the nurse question about their signed consent form for surgery?

a 54-year-old client with a fractured femur committed to a mental health unit

A nurse is working at a local emergency department. A nearby building explosion has occurred, and many of the victims involved are being brought to the facility. Which client would the nurse expect to be triaged first?

a 62-year-old with tachypnea

A licensed practical nurse (LPN) receives a report on several assigned clients at the beginning of the evening shift. The nurse would plan to collect data on which client first?

an older adult client with bacterial pneumonia experiencing periods of confusion

A nurse is implementing standard precautions when caring for all assigned clients, regardless of their diagnosis or infection status. The nurse demonstrates adherence to the guidelines for standard precautions by which action?

disposing of sharps into a puncture-resistant container

A client presents to the clinic because she thinks she may be pregnant. The licensed practical nurse is reviewing the client's medical record. Which finding would the nurse identify as a positive sign? fetal heart tones auscultated amenorrhea enlarging uterus quickening

fetal heart tones auscultated

When collecting data on a child with cellulitis, which symptoms would the nurse expect to find?

fever, edema, tenderness, and warmth at the site

The nurse complies with a client's request to administer his medication at 9 p.m. instead of 10 p.m. so he can go to sleep earlier. Which type of nursing intervention is the nurse utilizing?

independent

Which procedure performed by the nurse will require the use of sterile technique?

inserting an indwelling urinary catheter

The incidence of hospital-acquired pressure ulcers on the medical-surgical unit has increased. A nurse should inform the:

risk manager.

Which nursing data should be given the highest priority for a child with clinical findings related to tubercular meningitis?

signs of increased intracranial pressure (ICP)

A certified nursing assistant (CNA) is caring for a client with Clostridium difficile diarrhea and asks the nurse, "How can I keep from catching this from the client?" The nurse reminds the CNA to wash her hands and to ensure that the client is placed:

on contact isolation

The nurse, who is providing care for four clients, receives a report on the clients. Which report is an outcome indicator?

pain level 3/10 one hour after administration of pain medication

The health care provider orders contact precautions for a client with a draining wound. Which action should the nurse take to initiate these precautions?

place an isolation cart containing gloves and gowns outside the client's room.

The nurse obtains laboratory results on assigned clients during morning report. Which results needs to be immediately reported to the health care provider? glucose level 98 mg/dL hemoglobin 13.6 mg/dL potassium level 6.2 mg/dL creatinine level 0.6 mg/dL

potassium level 6.2 mg/dL

The nurse admits a client with Crohn's disease who is experiencing an exacerbation. Which intervention should the nurse make a priority of care?

promoting bowel rest

Professional regulations and laws that govern nursing practice are in place for what reason? to protect the safety of the public to ensure that practicing nurses are of good moral standing to limit the number of nurses in practice to ensure that enough new nurses are always available

to protect the safety of the public

The nurse is caring for a child with a Harrington rod placement. Which data gathered by the nurse would be of greatest concern 2 days postoperatively?

urine output less than 30 mL/hr

The nurse is assigned to care for a client with amnesia. When preparing to deliver care, which action will best meet the needs of this client?

use short, simple commands when providing instruction

A nurse is changing a client's dressing and providing wound care. Which activity should the nurse perform first?

wash hands thoroughly

In the emergency department, a client with facial lacerations states that her husband beat her with a shoe. After the health care team repairs her lacerations, she waits to be seen by the crisis intake nurse, who will evaluate the continued threat of violence. Suddenly the client's husband arrives, shouting that he wants to "finish the job." What is the first priority of the health care worker who witnesses this scene?

Calling a security guard and another staff member for assistance

A nurse is about to give a full-term neonate their first bath. What intervention should the nurse perform first? Obtain medicated soap. Check the neonate's temperature. Fill a tub with warm water. Scrub the neonate's skin to remove the vernix caseosa.

Check the neonate's temperature.

A client is admitted to the health care facility after 3 days of nausea, vomiting, and fever. Which nursing diagnosis takes highest priority for this client? Ineffective cardiopulmonary tissue perfusion related to hyperventilation Deficient fluid volume related to nausea and vomiting Excess fluid volume related to intracellular fluid shift Imbalanced nutrition: Less than body requirements related to decreased intake

Deficient fluid volume related to nausea and vomiting

A client with toxoplasmosis and cytomegalovirus is confused and has been dislodging his I.V. access. Which action would be most appropriate for the nurse to take?

Notifying the registered nurse and seeing if a nursing assistant is available to stay with the client

The nurse is teaching a group of unlicensed assistive personnel (UAP) about standard precautions. What information should the nurse include that best describes standard precautions? Select all that apply.

>Wear gloves when there is the potential for contact with a clientj's body fluid; >Wear gloves, a face shield, and a gown when contact with body fluids is possible

The client refused an injection, but the nurse administered it anyway. The client wants to sue the nurse. The attorney informs the client that this lawsuit must be filed within two years. What is this time frame called?

statute of limitation

A child diagnosed with tetralogy of Fallot has been ordered to undergo testing. Which test would the nurse prepare the child for that will indicate the direction and amount of shunting in this child?

cardiac catheterization

The nurse is caring for a child with symptomatic aortic stenosis. Which instruction should be provided to the child and parents.

Restrict exercise.

A nurse is seen accessing a client's medical record in an area where she doesn't provide care. Which action by the nurse is best? Notify the charge nurse and nursing supervisor of the incident. Ask the nurse why she's accessing the medical record and ask her to leave the client care area. No action is necessary. Notify security and the client's physician of the incident.

Notify the charge nurse and nursing supervisor of the incident.

A nurse must obtain the blood pressure of a client in airborne isolation. Which method is best to prevent transmission of infection to other clients by the equipment?

Leave the equipment in the room for use only with that client

An 80-year-old client has an advance directive that states "do not keep alive by any heroic means." The client suffered a heart attack, and the family is requesting full code. Which nursing action taken by the nurse is correct?

Use only pain medication to keep the client comfortable.

A nurse has been providing care to the same group of clients for 4 consecutive days. On day 5, she sees that her assignment has changed, and she is concerned about the continuity of care for these clients. What should the nurse do?

Voice her concerns about continuity of care with the charge nurse.

The nurse is teaching a group of client-care attendants about infection-control measures. The nurse tells the group that the first line of intervention for preventing the spread of infection is:

Washing hands

The nurse is revising a client's plan of care. Revision of the care plan takes place in which step of the nursing process? Planning Evaluation Data collection Implementation

Evaluation