NCLEX- PN

The LPN is explaining how to estimate sodium intake to a client prescribed the DASH diet. The DASH diet limits daily sodium intake to 1,500 mg, which must account for sodium in food and added to food. A quarter teaspoon of salt contains 500 mg of sodium. What is the maximum total amount of salt that the client could ingest per day, in teaspoons?

0.75 Explanation: Each quarter-teaspoon of table salt contains 500 mg sodium, and the daily maximum is 1500 mg. 1,500 mg/ 500 mg= 3 3 x 1/4 teaspoon= 3/4 teaspoon= 0.75 teaspoon

The LPN is preparing an agitated and confused client for surgery. For preoperative medication, the LPN administers morphine sulfate 5 mg IM and lorazepam 0.5 mg IM, as prescribed. The LPN should take which of the following precautions after the preoperative medication is administered? a) Ask the security guard to remain with the client b) Have the assistive personnel (AP) remain with the client c) Leave the client alone until the medications take effect d) Restrain the client with the help of a coworker

b Explanation: A client should not be left alone in an agitated state. A member of the health care staff should remain with this client.

The LPN knows that an assignment to which of the following clients would be appropriate? a) A client with emphysema scheduled for discharge b) A client in traction for treatment of a fractural femur c) A client with low back pain scheduled for a myelogram d) A client newly diagnosed with type 1 diabetes

b) A client in traction for treatment of a fractural femur Explanation: This client is in stable condition and can be cared for by an LPN

A client with type 1 diabetes returns to the recovery room one hour after an uneventful delivery of a 9 lb. 8 oz. (4,309 g) newborn. The nurse would expect which of these changes in the client's blood glucose level? a) From 220 to 180 mg/dL (12.21 to 10 mmol/L) b) From 110 to 80 mg/dL (6.1 to 4.4 mmol/L) c) From 90-120 mg/dL (5 to 6.7 mmol/L) d) From 100-140 mg/dL (5.6 to 7.8 mmol/L)

b) From 110-80 mg/dL

The client is waiting to be picked up by family after a cystogram. The LPN is reinforcing teaching about the client's home care for the first 48 hours. Which of the following instructions is appropriate for the LPN to include? Select all that apply. a) Decrease water and fluid intake b) Avoid consuming alcoholic beverages c) Seek medical attention for slight burning sensation when voiding d) Seek medical attention for appearance of blood in urine e) Apply heat to the lower abdomen to relieve pain and muscle spasm f) Report fever, chills, or increase pulse to the primary health care provider

b, e, f Explanation: The excretion of alcohol beverages might irritate the bladder, so it is advisable to avoid them for 2 days. Heat can relieve the pain and muscle spasm that are normal after the cystogram. Fever, chills or an increased pulse could signify an infection; the clinician should be notified. The client should increase not decrease water and other fluids. A slight burning sensation is an expected normal. Minor bleeding during the first 2 days can occur without being a cause for concern.

The LPN is checking the morning serum electrolyte results for a client. The LPN notes that the client's sodium is 142 mEq/L, potassium is 4.4 mEq/L, and chloride is 102 mEq/L. Which of the following should the nurse do first? a) Encourage the client to drink additional fluids b) Notify primary health care provider of electrolyte results c) Record electrolyte results in the client's medical record d) Withhold the client's potassium supplement

c Explanation: all of the lab results are within normal limits.

The LPN at the urology clinic is obtaining a health history from an elderly male client who reports back pain during urination and difficulty starting and stopping the urine flow. Which of the following goals is most important for the LPN to include in the client's plan of care? a) Pain medication b) Antibiotic administration c) Physical therapy d) Laboratory testing

d Explanation: A) The client will not benefit from pain medication because it will not address the cause of the discomfort during urination. B) Without lab test results it is not known if the client has an infection, so antibiotic therapy is not warranted. C) Physical therapy is not indicated for urological conditions. D) The client will have a urinalysis and a serum prostate-specific antigen (PSA) testing to help diagnose the condition.

When caring for a client diagnosed with anorexia nervosa, which of the following observations indications to the LPN that the client's condition is improving? a) The client eats all food on the meal tray b) The client asks friends to bring special foods c) The client weighs self daily d) The client has gained weight

d) The client has gained weight. Explanation: The client's weight is the most objective outcome measure in the evaluation of the client's problem.

The LPN is preparing to infuse 1 L of normal saline solution at a rate of 125 mL/hr. The drop factor for the IV tubing is 15 drops per mL. What is the drip rate per minute. Round to the nearest whole number.

31 Explanation: the formula used is mL/hr x drop factor divided by time in minutes. For this problem, you need to convert the hour to 60 minutes. 125mL/hr x 15 gtt/min divided by 60 min. = 1,875/60= 31.25 gtt/min Round to the nearest whole number

The LPN notes that the client is allergic to an ordered medication. Which of the following is the correct action by the LPN? a) Administer the medication as the primary health care provider ordered it. b) Administer the medication and closely observe the client c) Call the pharmacist to verify potential allergic responses d) Call the primary health care provider and report the medication allergy

d) Call the primary health care provider and report the medication allergy Explanation: The LPN must notify the primary HCP regarding the client's allergy to revise the medication order.

The primary health care provider is applying a cast to an infant for treatment of talipes equinovarus. Which of the following instructions in MOST essential for the LPN to give to the child's parent's regarding care? a) Offer age-appropriate toys b) Visit clinic frequently for cast adjustments c) Give an analgesic as needed d) Check circulation in the cast extremity

d) Check circulation in cast extremity Explanation: A possible complication that can occur after cast application is impaired circulation. All of these choices might be included in family teaching, but checking the child's circulation is highest priority.

The nurse is preparing to insert an indwelling urinary catheter in a female client. Arrange the following steps in the order the LPN should perform them. All options must be used. a) Open the sterile pack between the client's legs b) Wipe the urinary meatus with a cotton ball saturated with cleansing solution c) Inflate the balloon of the catheter to check for leaks d) Place the client supine with knees flexed e) Lubricate the tip of the catheter f) Put on the sterile gloves

d, a, f, c, e, b

The LPN in the outpatient clinic notes that the blood pressure for a client is 190/100 mm Hg. The LPN should take which of the following actions? a) Report the BP reading to the RN b) Wait 20 min and retake the BP c) Use a different cuff and retake the BP d) Position the client supine with feet elevated

a) Report the BP reading to the RN. Explanation: The LPN is responsible for data collection and should report findings that are abnormal to the supervising RN. Immediate action should be taken. It is unnecessary to recheck BP using other equipment or to position client supine with feet elevated.

A client is admitted to the hospital with a ruptured ectopic pregnancy . A laparotomy is scheduled. Preoperatively, which of the following interventions is most important for the LPN to include on the client's plan of care? a) Fluid replacement b) Therapeutic communication c) Emotional support d) Oxygen therapy

a Explanation: An ectopic pregnancy is implantation of the fertilized ovum in a site other than the endometrial lining, usually the fallopian tube. Initially the pregnancy is normal but as the embryo outgrows the fallopian tube, the tube ruptures, causing extensive bleeding into the abdominal cavity.

The LPN is caring for a client after a motor vehicle accident. The LPN observes that the client is restless, anxious, and has tremors of the hands. The family reports that the client has consumed 4-6 beers a day for the past 8 years. What is the priority action for the LPN to take? a) Reorient client to the environment frequently b) Maintain the client in a cool, darkened room c) Assist the client to drink more isotonic fluids d) Administer thiamine 100 mg intramuscularly

a Explanation: A client may experience hallucinations during alcohol withdrawal. Reorienting the client to the environment helps maintain client safety during hallucinations. Some light is recommended to decrease the intensity of the hallucinations. Bright lighting is not recommended but soft lighting is appropriate to observe surroundings. Answers c and d do not decrease the risk of injury.

The primary HCP has ordered a condom catheter for a male client. Which of the following is the most important question the LPN should ask the client before carrying out this order? a) "Do you have a latex allergy?" b) "Do you have a history of urinary tract infections?" c) "Do you have a history of frequent nocturia?" d) "Have you been circumcised?"

a Explanation: A) A latex allergy would preclude the use of some condom catheters. B) Research has shown that condom catheters cause fewer UTIs than indwelling urinary catheters. C) After the primary HCP has ordered a condom catheter, the client's voiding pattern is not an issue. D) Circumcision is not a contraindication to use a condom catheter.

A child biking to school hit the curb and then fell, injuring his leg. The LPN was called and found the child alert and conscious, but in severe pain with a possible right femur fracture. Which of the following is the first action that the LPN should take? a) Immobilize the affected limb with a splint and ask the client not to move b) Collect data of the circumstances surrounding the accident c) Place the client in a semi-fowlers position to facilitate breathing d) Check pedal pulse and blanching sign in both legs and compare the findings

a Explanation: First determine whether you should be collecting data or implementing. The LPN has determined that the child has a possible femur fracture. This implies that the data collection has been completed. Eliminate answers a and d. The question does not indicate any respiratory distress therefore you are left with answer a.

A client is admitted to the hospital with influenza-like symptoms. When taking the client's history, the LPN learns that the client had been taking digoxin 0.125 mg PO daily and furosemide 40 mg PO daily for 3 years. Last month the primary health care provider changed the prescription for digoxin 0.25 mg daily. The LPN would expect the primary health care provider to prescribe which of the following laboratory tests? a) Serum electrolyte and digoxin levels b) Hemoglobin level and hematocrit c) Cardiac enzymes and arterial blood gas analysis d) Blood culture and sensitivity and urinalysis

a Explanation: Furosemide is a loop diuretic that inhibits reabsorption of sodium and chloride; side effects include hypotension, hypokalemia, GI upset and weakness. Hypokalemia may increase the client's risk of digitalis toxicity.

A preschool-age child is brought to the emergency department (ED) by the parents for treatment of a femur fracture. When asked how the injury occurred, the parents state that the child fell from the sofa. On examination, the LPN finds old and new lesions on the child's buttocks. Which of the following statements most appropriately reflects how the LPN should document these findings? a) "six lesions in various stages of healing noted on buttocks" b) "multiple lesions on buttocks due to child abuse" c) "lesions noted on buttocks from unknown causes" d) several lesions noted on buttocks

a Explanation: Good documenting is accurate, objective, concise and complete. It must reflect the client's current status.

The LPN notes that there is no urine in the client's urinary drainage bag 3 hours after the bag was last emptied. Which of the following actions should the LPN take first? a) Check for kinks in the urinary drainage tubing b) Insert a new indwelling urinary catheter c) Irrigate existing indwelling urinary catheter d) Notify client's primary health care provider

a Explanation: If there is no urine in urinary drainage bag, could there be an obstruction in the drainage system? Checking for kinks in the urinary drainage tubing could provide a simple explanation for your observation. Inserting a new indwelling urinary catheter may address a possible catheter obstruction but increases the client's risk for catheter associated urinary tract infection.

The LPN is caring for a child whose parent that reports that the child experienced abdominal cramps and diarrhea after ingesting milk. Which of the following test results would rule out the diagnosis of lactose intolerance? a) Random serum glucose level 20 mg/dL greater than the fasting serum glucose level. b) Random serum glucose level 20 mg/dL less than the fasting serum glucose level c) Fasting serum glucose level results are equal to the random serum glucose level result d) Fasting serum glucose level 10 mg/dL greater than the random serum glucose level

a Explanation: Lactose intolerance prevents the conversion of lactose into glucose. If test results show a random serum glucose level significantly greater (20 mg/dL) than the fasting serum glucose level, then lactose is being converted into glucose; this rules out the diagnosis of lactose intolerance.

A client is hospitalized with a diagnosis of atrial fibrillation. The primary health care provider prescribes Heparin 5,000 units every 12 hours to be given by subcutaneous injection and daily partial thromboplastin time (PTT). The result of the client's most recent PTT is 55 seconds. Which of the following actions should be taken by the LPN? a) Document the results and administer the heparin b) Withhold the heparin c) Notify the primary health care provider of the test results d) Have the test repeated

a Explanation: Normal PTT ranges 20-45 seconds. Therapeutic range PTT for a client receiving heparin, an anticoagulant, ranges 1.5-2 times the control or normal level. To calculate the therapeutic range, take the lower number for the normal range for a PTT (20) and multiply it by 1.5. The result is 30. Multiply the higher number (45) by 2. The result is 90. Thus the therapeutic ranges from 30-90 seconds. Therapeutic PTT ranges 30-90 seconds, the goal of therapy. Because 55 seconds falls within the 30-90 seconds there is no need to notify the health care provider, withhold the medication, or repeat the test.

A client is admitted to the hospital in active labor. After delivery of a healthy infant, the client decides to bottle feed. Which of the following statements by the client after a teaching session indicates to the LPN that the client needs further instruction? a) "I'll pump my breasts and use warm packs to relieve breast pain" b) "I'll wear a tight bra a wear ice packs to relieve engorgement discomfort" c) "I'll take the prescribed pain medication when I have pain or discomfort" d) "I'll take the prescribed pills to help stop the production of milk"

a Explanation: This action will only further stimulate milk production. Other answers are true statements. Remember we are looking for inaccurate information that would require further teaching.

A pediatric client undergoes a tonsillectomy for treatment of chronic tonsillitis unresponsive to antibiotic therapy. After surgery, the client is brought to the clinical unit. Which of the following actions should the LPN include in the client's plan of care? a)Institute measures to minimize crying b) Perform postural drainage every 2 hours c) Cough and deep breathe hourly d) Provide ice-cream as tolerated

a Explanation: What will cause the client the least amount of harm? Minimizing crying will help prevent bleeding. The LPN must prevent post-operative hemorrhage, a complication seen after this type of surgery. Crying would irritate the child's throat and increase the chance of hemorrhage. Postural drainage may cause bleeding. Cough and deep breathing may cause bleeding. Providing ice-cream may cause the child to clear throat, causing bleeding.

Which of the following symptoms observed by the LPN during the first 24 hours after a percutaneous liver biopsy would indicate a complication from the procedure? a) Anorexia, nausea and vomiting b) Abdominal distension and discomfort c) Pulse 112 beats/minute and blood pressure 86/60 mm Hg d) Redness and pain at the biopsy site

c) Pulse 112 beats/min and BP 86/60 mm Hg. Explanation: An increased pulse and decreased BP indicate shock. Shock is a result of hemorrhage. Hemorrhage is a major complication.

A client admitted with a diagnosis of dementia attempts several times to remove the nasogastric tube. The LPN receives an order for wrist restraints. Which of the following actions by the LPN is most appropriate? a) Attach the ties of the wrist restraints to the client's bed frame b) Perform daily range of motion exercises to the restrained extremities c) Remove the restraints when the client is out of bed in a wheelchair d) Explain restraint need to the family only, because the client is confused

a Explanation: What will cause the least amount of harm to this client? Attaching restraints to the clients bed will not harm the patient and will allow the nurse to raise and lower the side rail without injury to the client. Performing daily ROM exercises will not harm the client, however they should be performed every 2-4 hours to prevent loss of joint mobility. Removing the restraints when the client is out of bed and in a wheelchair will be harmful to the client. Restraints should not be removed when the client in unattended. Explaining the need for restraints only to the family can cause harm to the client. Restraints can increase the confusion or combativeness of the client. Even though confused, the client needs to receive an explanation.

The LPN doubts the accuracy of a medication order in the client's medication administration record (MAR). Which of the following actions should the LPN take first? a) Compare order in MAR to order in medical record b) Contact the prescribing primary HCP to question the order c) Consult with the hospital pharmacist about the accuracy of the medication order d) Look up medication in nursing drug book and compare information to medication order

a Explanation: What will protect my client the most? answer a will provide clarification regarding the questioned medication. The NCLEX test makers want to know what decision you are going to make to protect your client, not what decision the primary HCP will make.

The primary health care provider prescribes amoxicillin 150 mg PO in oral suspension every 8 hours for a 3-year old client. The LPN enters the client's room to administer the medication and discovers that the client does not have an identification bracelet. Which of the following actions should the LPN take? a) Ask the parent's to state their child's name b) Ask the child to say their first and last name c) Have a coworker identify the child before giving the medication d) Hold the medication until an identification bracelet can be obtained

a) Ask the parents to state their child's name. Explanation: This action will allow the nurse to correctly identify the child and enable the nurse to give the medication on time

The LPN is obtaining a health history from a client admitted with acute glomerulonephritis. Which of the following history finding is significant for the diagnosis of acute glomerulonephritis? a) Personal history of sore throat 10 days ago b) Family history of chronic glomerulonephritis c) Personal history of renal calculus 2 years ago d) Personal history of renal trauma several years ago

a) Personal history of sore throat 10 days ago. Explanation: Acute glomerulonephritis, an immune disorder that affects the kidneys, can be causes by group A Streptococcus. It usually occurs about 10 days after strep throat or scarlet fever and about 21 days after a group A Streptococcus skin infection.

The LPN is caring for a client diagnosed with a right sided stroke with dysphagia. Which of the following actions by the LPN reflects appropriate care for the client? Select all that apply a) The LPN assesses the client's ability to swallow b) The LPN positions the client the head of the bed elevated 25 degrees c) The LPN offers the client scrambled eggs d) The LPN instructs the client to place food on the left side of the mouth e) The LPN turns off the television

a, c, and e Explanation: the nurse needs to make sure the client is able to swallow food before giving him anything to eat. The result of this evaluation will also determine whether the nurse should offer clear liquids or thickened liquids. Some clients will require thickened liquids while others will not. The client should be sitting upright in a chair or with the head of the bed elevated to at least 30 degrees. Soft or semi-soft foods are more easily tolerated than a regular diet. So scrambled eggs is an appropriate choice. If the client had a right-sided stroke, that means the left side of the client's body is affected. The food should be placed on the unaffected side- the right side of the mouth for this client. Many clients are easily distracted after a stroke. If the client has dysphasia, you don't want him to aspirate while being distracted by the television. It is best to turn the tv off during meals.

A client is being treated in the burn unit for second and third degree burns over 45% of his body. The primary health care provider prescribes silver sulfadiazine cream application. Which method is BEST for the LPN to apply this medication? a) Sterile dressings soaked in saline b) Sterile tongue depressor c) Sterile gloved hand d) Sterile cotton-tipped applicator

c) Sterile gloved hand Explanation: A sterile gloved hand will cause the least trauma to tissues and will decrease the chances of breaking blisters.

The client is about to be discharged home with a portable oxygen delivery system. The LPN knows that which of the following education topics is most important for the client's family? a) Correct use of prescribed nebulizers and inhalers b) Prohibition of flame and heat sources in the same room c) Relaxation techniques such as visualization or meditation d) Maintenance of adequate hydration and nutrition

b Explanation: "Most important" indicates priority. Eliminate psychosocial answers (c) Consider outcome of each answer. A) Treatment education is important but basic physical safety takes priority. B) Flame or any source of heat such as a lit cigarette, candle or space heater, could cause a fatal fire in the presence of an oxygen delivery system. D) Education about basic physiological needs is important, but warning about the risk of a fatal fire takes priority.

The LPN is observing the client who had just eaten lunch having an episode of projectile vomiting. Which of the following actions should the nurse take first? a) Give client an emesis basin b) Obtain the client's vital signs c) Contact client's primary HCP d) Record the client's food intake from client's meal tray

b Explanation: "First action" indicates priority. Determine if data collection or implementation is more important. A) An emesis basin is inadequate to contain further projectile vomiting. B) Data collection about the client's status is needed before taking action. C) The primary HCP will inquire about the client's VS. D) Recent food intake is unlikely to have cause projectile vomiting.

The LPN is preparing to administer isoniazid 300 mg PO. Which of the following is a priority laboratory value to monitor before administering the medication? a) B-type natriuretic peptide (BNP) b) Aspartate aminotransferase (AST) c) Potassium d) Vitamin B12

b Explanation: AST increases in the presence of liver injury. Liver function must be monitored in clients taking isoniazid. The other lab values are not affected by liver function.

Within 5 minutes of beginning a blood transfusion, the client reports feeling hot and diaphoretic, and the LPN observes that the client appears flushed. Which of the following actions should the nurse take first? a) Notify primary HCP b) Stop blood transfusion immediately c) Increase normal saline solution drip rate d) Obtain the client's vital signs immediately

b Explanation: Discontinue immediately to avoid the risk of kidney damage resulting from the possible red blood cell destruction. The primary HCP can be notified after the correct actions have taken place. Vitals should be taken after stopping the transfusion.

The LPN is reinforcing instructions for a client taking clopidogrel 75 mg PO daily. Which statements by the client indicates understanding of reinforced instructions? a) "It will be necessary for me to have frequent blood tests done now" b) "I will need to discontinue the garlic tablets I take to control cholesterol" c) "I can continue to take several ibuprofen a day for my lower bakc pain" d) "I will need to make sure to take a daily multivitamin tablet now"

b Explanation: Garlic and clopidogrel both inhibit platelet function and increase the risk of bleeding.

A client with a history of heart failure visits the clinic. The client states "I have not been feeling like my old self for about 2 weeks." It would be most important for the LPN to ask which of the following questions? a) "Do your ankles swell at the end of the day?" b) "How do you position yourself for sleep?" c) "How do feel after you eat your dinner?" d) "Do you have chest pain when you inhale?"

b Explanation: If the client sleeps flat in the bed, breathing is not compromised. If the client sleeps in a recliner, the client experiences orthopnea, is a symptoms of L sided heart failure. This would be a priority. Edema is a symptom of R sided heart failure. This is not priority because L sided HF affects the lungs. Bloating after meals in a symptom of R sided HF. This is not as important as breathing problems. Pain on inspiration may indicate irritation of the parietal pleura of the lung, which is not associated with HF.

The LPN is caring for a client admitted with fever, vomiting, and diarrhea. The LPN sees the following nursing diagnosis on the client's care plan: "fluid volume deficit." Which of the following changes in laboratory tests results would demonstrate an improvement in the client's condition? a) Urine specific gravity, 1.015; hematocrit, 37% b) Urine specific gravity, 1.020; hematocrit, 45% c) Urine specific gravity, 1.032; hematocrit, 52% d) Urine specific gravity, 1.025; hematocrit, 35%

b Explanation: Normal urine specific gravity ranges 1.010-1.030 and normal hematocrit ranges 42-50% for male and 40-48% for female. Fluid volume deficit occurs when fluids and electrolytes are lost in the same proportion as they exist in the body. When a client becomes dehydrated, both the urine specific gravity and hematocrit become elevated.

The LPN is planning care for a 4 year old client who has been sexually abused by the father. Play therapy is scheduled. The LPN knows that the primary goal of play therapy for a 4 year old client is which of the following? a) Provide the opportunity to express anger and hostility by playing with dolls b) Promote communication because the client may lack capacity to verbally express perceptions c) Assess whether the client functions at age-appropriate developmental level d) Reveal the type of abuse experienced through direct observation of the client at play

b Explanation: Play is the universal language of children. The purpose of play therapy is to give children the opportunity to communicate using their own language.

The primary health care provider orders furosemide and spironolactone for a client. Prior to administering the medication, the LPN determines that the client's potassium 3.2 mEq. In addition to notifying the supervising RN, the LPN should anticipate taking which of the following actions? a) Hold either the furosemide or spironolactone b) Administer the spironolactone only c) Administer the furosemide only d) Administer the furosemide and spironolactone

b Explanation: Potassium level falls below the normal level of 3.5-5 mEq. Furosemide is a potassium wasting diuretic and spironolactone is a potassium sparing diuretic. There is no reason to hold the spironolactone because the client has a low potassium level. You should not administer furosemide because the potassium level is already low.

Parent's bring a school age client with a history of type 1 diabetes and several days of illness to the emergency department (ED). Which of the following laboratory test results would the LPN expect if the client is experiencing diabetic ketoacidosis? a) Serum glucose 140 mg/dL (7.8 mmol/L) b) Serum creatine 5.2 mg/dL c) Blood pH 7.28 d) Hematocrit 38%

c) blood pH 7.28 Explanation: Normal blood pH is 7.35-7.45. A blood pH of 7.28 indicates diabetic ketoacidosis

The LPN is reviewing medication information with a female client who has been prescribed sertraline daily. Which of the following statements by the client indicates a need for further instructions? a) "I will continue to take my birth control pills" b) "If these pills don't work in 2 weeks. I will stop taking them" c) "I will take my pill first thing in the morning" d) "I will skip a missed dose if it is almost time for my next one"

b Explanation: Sertraline may take 4 weeks to have a positive effect on the client's symptoms; the client should not stop taking the medication without consulting with the primary HCP. It is important to take this medication at the same time each day but not necessarily in the morning. A missed dose of Sertraline should be omitted if it is almost time for the next dose. It can cause birth defects if taken during pregnancy; the client should continue taking contraceptives.

A client who sustained a left femur fracture in a motor vehicle accident is being treated with balanced-suspension skeletal traction using a Thomas splint and a Pearson attachment. The client reports "terrible" pain in the left thigh. Which of the following should the LPN do first? a) Determine that the traction weights and ropes are aligned and hanging free b) Ask the client about the characteristics and location of the pain c) Check the Thomas splint and Pearson attachments for proper positioning d) Explain to client that pain in the affected leg is expected

b Explanation: This answer choice focuses on the client first. Pain should be thoroughly investigated by the LPN.

A client with type 1 diabetes contact the home care LPN to report nausea and abdominal pain. The LPN should advise the client to do which of the following? a) "Hold your regular dose of insulin" b) "Check your blood glucose level every 3-4 hours" c) "Increase consumption of foods containing simple sugars" d) Increase your activity level"

b Explanation: This is data collection. Before you can advise the client, you must identify whether the client is hypoglycemic or hyperglycemic. All the other answers are implementation and are skipping the step of assessment.

The LPN is approached in the elevator by an employee from another unit. The employee states that a close friend is a client on the LPN unit. The employee asks about the friend's condition and laboratory test results. The LPN should do which of the following? a) Answer employees question softly to prevent others from overhearing b) Refuse to discuss the friend's medical condition with the employee c) Refer the employee to the client's primary health care provider for information d) Tell the employee the client's normal test results

b Explanation: This option does not violate the client's right to privacy and confidentiality. Discussing client information in a public place breaches confidentiality.

The primary HCP orders a nasogastric (NG) tube inserted and connected to low intermittent suction for a client with an intestinal obstruction. Two hours after NG tube insertion, the client vomits 200 mL. While irrigating the NG tube, the LPN notes resistance. Which of the following actions should the LPN take first? a) Replace the NG tube with a larger one b) Turn the client on the left side c) Implement continuous NG tube suction d) Continue NG tube irrigation

b Explanation: This question is about procedure. What should the nurse do when resistance is met while irrigating an NG tube? If you're unsure about procedure, think safety. All the answer choices implementation. Which selection will cause the client the least amount of harm? Replacing the NG tube with a larger one could harm the client by damaging the mucosa. Turning the client to the left side would not harm the client. The tip of the tube may be against the stomach wall. Repositioning the client might allow the tip to lie unobstructed in the stomach. Changing the suction from intermittent to continuous is never done because it will erode the mucosa. Continuing irrigation where there is resistance might be harmful. Never force an irrigation.

The LPN is caring for a client receiving haloperidol 2 mg PO bid. The LPN assists the client to choose which of the following menus? a) 6 oz. roast beef, baked potato, salad with dressing, dill pickle, baked apple pie, and milk b) 3 oz. baked chicken, green beans, steamed rice, 1 slice of bread, banana, and milk c) 6 oz. burger on bun, french fries, apple, chocolate chip cookie, and milk to drink 30 minutes after mealtime d) 3 oz. baked fish, slice of bread, broccoli, ice cream, and pineapple juice to drink 60 min after mealtime

b Explanation: haloperidol is an antipsychotic medication. There are no diet restrictions. Because there is no other information given you must consider it to be a regular balanced diet. Answer b is the MOST regular balanced diet. It contains foods from each food group. Eliminate all those answers that are not balanced, high in fat or salt. There is no indication that fluid intake should not be delayed.

A client reporting nausea, vomiting and severe right upper quadrant pain is admitted to the medical/surgical unit. The client's temperature is 101.3 degrees F and an abdominal x-ray reveals an enlarged gallbladder. The client is scheduled for surgery. Which of the following actions should the LPN take first? a) Assess the client's need for dietary teaching b) Evaluate the client's fluid and electrolyte status c) Examine the client's health history for allergies to antibiotics d) Determine whether the client has signed consent for surgery

b) Evaluate the client's fluid and electrolyte status Explanation: Hypokalemia and hypomagnesemia commonly occur repeated vomiting.

The LPN is delivering external cardiac compression to a client during cardiopulmonary resuscitation (CPR). Which of the following actions by the LPN is BEST? a) Maintain a position close to the client's side with the nurse's knees apart b) Position hands on the lower half of the sternum during compressions c) Lean on chest between compressions to prevent full chest wall recoil d) Check for a return of the client's pulse after every 8 breaths by the nurse

b) Position hands on the lower half of the sternum during compressions. Explanation: The nurse's hands should be positioned on the lower half of the client's sternum during compressions with elbows locked, arms straight, and shoulders positioned directly over hands. The nurse should avoid leaning on the chest between compressions to allow for full chest wall recoil.

An adolescent is brought to the emergency department (ED) for a left femur fracture sustained in a sledding accident. The primary HCP reduces the fracture and applies a cast. The client is taught how to use crutches for ambulating without bearing weight on the left leg. The LPN would expect the client to learn which of the following crutch-walking gaits? a) two-point gait b) three-point gait c) four-point gait d) swing-through gait

b) three-point gait Explanation: both crutches and one foot are on the ground. This would be appropriate for a non-weight bearing client.

The LPN is preparing to reinforce instructions for a client about the use of an incentive spirometer. Arrange the following steps in the order the client should perform them. All options must be used. a) Seal lips around the mouth piece b) Assume high-fowlers position c) Exhale slowly and cough d) Hold breath for 3-5 seconds e) Inhale slowly and deeply

b, a, e, d, c Explanation: The purpose of the IS is to open the alveoli and lower airway passages and increase oxygenation. The upright position allows client to inhale deeply and to promote lung expansion. Next client must have a tight seal around the mouth piece. To make the volume indicator move, the client must inhale slowly and deeply. To achieve maximum expansion of the lungs, the client should hold the inhalation for 3-5 seconds. The last step is slow exhalation, which will continue to promote expansion of the lower airways.

The LPN is reinforcing teaching for a client after a right mastectomy and axillary lymph node dissection. Which statement by the client requires further interventions by the LPN? Select all that apply a) "I will wear gloves and long sleeves whenever I go out and work on my garden." b) "The risk for my arm swelling will decrease one year after my treatment is completed." c) "I will sleep with my right arm elevated on a small flat pillow from now on." d) "If my right arm begins to feel heavy, I should contact my primary health care provider." e) "It will be necessary for me to wear a compression bandage for the rest of my life."

b, c, e Explanation: We are looking for false information. The client is at risk for lymphedema for the rest of her life. The arm should be elevated above the level of the heart at night. Compression bandages may be used if the client develops acute lymphedema. Compression bandages are not routinely used after mastectomy and lymph node dissection. For answer a- This is a true statement. Any injury to the right arm including insect bites or scrapes may become infected and cause lymphedema. answer d- This is a true statement

An LPN is caring for a client whose vaginal delivery resulted in a stillborn infant. Which of the following actions by the nurse is the most important? a) Be available to the client to listen to expressions of grief b) Provide the client with appropriate fluid replacement c) Check the client's perineal pad frequently for excess bleeding d) Tell the client about measures to cope with severe uterine pain

c Explanation: "Most important" indicates priority. Use Maslow's hierarchy of needs. Eliminate psychosocial options (a, d). B) There is no evidence of dehydration for this client. C) The nurse should check the client's perineal pad frequently for excess bleeding. Circulation is the third of the ABCs.

The client is being treated for heart failure with diuretic therapy. Which of the following findings best indicates to the LPN that the client's condition is improving? a) The client's weight has remained stable since admission b) The client's systolic blood pressure has decreased c) There are fewer crackles heard when auscultating the client's lungs d) The client's urinary output is 1,500 mL per day

c Explanation: A client with heart failure has crackles due to pulmonary edema. Diuretics are given to promote excretion of sodium and water through the kidneys. Decreased crackles would indicate that the pulmonary edema is improving.

The client comes to the urgent care clinic reporting "I've just stepped on a rusty nail at a construction site." The LPN observes a deep puncture wound on the sole of the right foot. What order would the nurse expect to receive from the primary HCP for this client? a) Complete blood count b) Wound culture c) Tetanus vaccine d) Lumbar puncture

c Explanation: A deep puncture wound provides an ideal reservoir for the growth of Clostridium tetani (common in soils, dust, and feces and on human skin). To prevent tetanus, a potentially fatal bacterial infection, the primary HCP would order the tetanus vaccine. A CBC is not necessary because the client has not suffered a significant amount of blood loss. Wound culture is not necessary for a new wound. Lumbar punctures withdraw spinal fluid from the spinal column to identify conditions of the brain or spine, not to manage a puncture wound in the foot.

The client is caring for client with a diagnosis of stroke. The LPN is feeding the client in a chair when the client suddenly begins to choke. Which of the following actions should the LPN take first? a) Check the client for breathlessness b) Leave the client in the chair and apply vigorous abdominal or chest thrusts c) Ask the client "are you choking?" d) Return the client to the bed and apply vigorous abdominal or chest thrusts

c Explanation: Determine whether you should collect data or implement. The client has begun to choke. This alerts the nurse that there is a problem. The first step in the nursing process is data collection. Asking the client if they are choking will show whether they can speak or cough. This indicates airway obstruction. Breathlessness should only be checked in an unconscious patient.

The LPN is caring for a client immediately after a paracentesis. It is most important for the LPN to ask which of the following questions? a) "Do your clothes feel tight?" b) "Do you need to void?" c) "Are you feeling dizzy?" d) "Do you have any pain?"

c Explanation: Dizziness is caused by cerebral perfusion due to fall in BP. Hypotension and hypovolemic shock are complications of a paracentesis due to removal of a large volume of fluid. Pain is an expected outcome. Clothes should fit looser because the abdominal girth had decreased after fluid has been removed with a paracentesis.

A frail client is admitted to the hospital for dehydration. The client is incontinent of urine and stool. The LPN should give which of the following nursing diagnoses the highest priority? a) Body image disturbance related to immobility b) Self-esteem disturbance related to loss of independence c) Impaired nutrition: intake less than body fluid requirements d) Risk for impaired skin integrity related to incontinence

c Explanation: Remember the ABCs. Eliminate psychosocial needs (a, b). C) The client's dehydration impairs normal circulation. D) Although this physiological risk is present, circulation takes precedence over skin injury.

A client admitted to the hospital for treatment of active tuberculosis (TB). The LPN reinforces teaching about TB. Which of the following statements by the client indicates to the LPN that further teaching is necessary? a) "I will have to take medications for 6 months" b) "I should cover my nose and mouth when coughing or sneezing" c) "I will remain in isolation for at least 6 weeks" d) "I will always have a positive skin test for TB"

c Explanation: The client does not need to be isolated for 6 weeks. The client's activities will be restricted for about 2-3 weeks after medication therapy is initiated. The client will need to take medication, such as isonicotinyl hydrazine (INH) for 6 months or longer. TB can be transmitted by droplet contamination, so the client should cover their nose and mouth when coughing or sneezing. A positive skin test indicates that the client has developed antibodies to the tuberculosis bacillus.

The LPN is explaining the procedure for a clean catch urine specimen collection for culture and sensitivity to a male client. Which of the following explanation by the LPN would be most accurate? a) "The urinary meatus is cleansed with an iodine solution and then a urinary drainage catheter is inserted to obtain urine" b) "You will be asked to empty your bladder one-half hour before the test; you will then be asked to void into a container" c) "Before voiding, the urinary meatus is cleansed with an iodine solution and urine is voided into a sterile container; the container must not touch the penis" d) "You must void a few drops of urine, then stop; then void the remaining urine into a clean container, which should be immediately covered"

c Explanation: This is true of a clean catch urine specimen. Catheterization is not used due to increased risk of infection. For answer b, this describes a double voided specimen. This action is usually done when testing for glucose and ketones. It is not relevant for a clean-catch urine specimen. For answer d, the answer is mostly correct except for the container must be sterile not "clean"

The LPN is observing that a client's radial pulse is now 56 bpm. It was 72 bpm 4 hours ago. What is the most important action for the LPN to take? a) Check the O2 saturation levrel b) Begin O2 at 2L/min by nasal cannula c) Obtain the client's BP d) Palpate bilateral pedal pulse strength

c Explanation: What happens when a client's heart decreases significantly? Cardiac output may decrease, leading to decrease perfusion of vital organs. Determine if data collection or implementation is more important. A) O2 levels indicate the amount of O2 attached to the RBCs. O2 levels will not be affected by cardiac output. They are affected by altered respiratory function. B) Giving supplemental O2 may be an appropriate action but not a priority action. C) If heart rate decreases, cardiac output and BP decrease, decreasing blood flow to the brain and other vital organs and increasing risk of organ damage. D) Observing bilateral pulse strength may be an appropriate action but not the most important. The priority is to gather data related to blood flow to vital organs.

A client with a history of bipolar disorder is admitted to the psychiatric hospital. The client was found by the police attempting to climb onto the wing of a plane at the airport. A family member reports that the client has not eaten or slept in 2 days, and suspects that the client has stopped taking lithium. On admission, the LPN should place the highest priority on which of the following client care needs? a) Reinforcing to the client the importance of taking lithium as prescribed b) Providing the client with a safe environment with few distractions c) Arranging for food and rest for the client d) Setting limits on the client's behavior

c Explanation: When asking what is the highest priority you should eliminate all psychosocial answers (a, d). Apply the ABC's. None of the remaining answers relate to the ABCs. Next use Maslow's hierarchy to select answer c.

An hour after admission to the nursery, the LPN observes a newborn having spontaneous, jerky limb movements. The newborn's mother had gestational diabetes mellitus (GDM) during pregnancy. Which of the following actions should the LPN take first? a) Administer dextrose water b) Call the primary HCP immediately c) Determine the blood glucose level d) Observe the newborn for associated symptoms

c Explanation: You must complete data collection before you implement nursing care.

A client admitted to the hospital in premature labor has been treated successfully. The client is to receive a regimen of betamethasone. Which of the following statements by the client indicates to the LPN that the client understands the teaching about the medication? a) "As long as I receive my medication, I won't deliver prematurely" b) "It is important that I count the fetal movements for one hour, twice a day" c) "I have insomnia and a rapid heart beat while on this medication" d) "Bed rest is necessary in order for the medication to work properly"

c Explanation: You should ask yourself- what is true about betamethasone. Betamethasone is a corticosteroid. Side effects include: insomnia, increased maternal heart rate, and hypertension. It will help with fetal lung maturation in case the client delivers prematurely, but it does not prevent premature delivery. Bed rest does not influence whether or not the medication will work.

The LPN is preparing to administer an intramuscular injection to a 6 month old client. Identify the area where the injection should be given? a) deltoid muscle b) hip c) vastus lateralis d) buttocks

c Explanation: For infants IM injection should be given in the middle third of the anterior thigh and the midline lateral thigh. To identify the IM injection site, locate the greater trochanter, then the knee joint; divide the area between the trochanter and the knee joint into thirds and note the middle third. Then locate the area between the midline anterior thigh and the midline of the outer aspect of the thigh.

After receiving hand off care report from the RN, which of the following clients should the LPN see first? a) A client refusing to take sucralfate before mealtime b) A client with left-sided weakness asking for assistance to the commode c) A client reporting chills who is scheduled for a cholecystectomy d) A client with a nasogastric tube who had a bowel resection yesterday

c) A client reporting chills who is scheduled for a cholecystectomy Explanation: This client is the least stable

A client comes to the nurse's station and inquires about going the cafeteria to get something to eat. The client becomes verbally abusive when told personal privileges do not include going to the cafeteria. Which of the following approaches by the LPN would be MOST effective? a) Tell the client to speak softly to avoid disturbing the other clients b) Ask what the client wants from the cafeteria and have it delivered to the client's room c) Calmly but firmly escort the client back to the client's room d) Assign the assistive personnel (AP) to accompany the client to the cafeteria

c) Calmly but firmly escort the client back to the client's room Explanation: The nurse should not reinforce abusive behavior. Client's need consistent and clearly defined expectations and limits.

A client had a permanent pacemaker implanted one year ago. The client returns to the outpatient clinic for suspected pacemaker battery failure. It is most important for the LPN to assess which of the following? a) abdominal pain, nausea and vomiting b) wheezing on exertion, cyanosis, and orthopnea c) palpitations, shortness of breath, and dizziness d) chest pain, headache, and diaphoresis

c) palpitations, shortness of breath and dizziness Explanation: Palpitations, SOB, dizziness, lightheadedness, syncope, irregular heart rate, and tachycardia or bradycardia may occur with pacemaker battery failure.

The LPN is caring for a client diagnosed with possible liver damage following a motor vehicle accident. Which of the following actions by the LPN reflects appropriate care for this client? Select all that apply. a) Prepare for client's inability to self-bathe b) Make sure the side rails are up at all times c) Report the client's nosebleed to the unit charge nurse immediately d) Remove the hospital bed pillow to help the client lie flat e) Inspect the client's skin and eye color for signs of jaundice

c, e Explanation: bleeding especially from the nose and the rectum is consistent with internal organ damage, including liver damage. A yellow cast on the skin or yellowed whites of the eyes are consistent with jaundice.

On admission to the hospital, an elderly client is confused and appears disheveled and restless. During the second day on the unit, an LPN approaches the client to administer medication. The LPN is unable to identify the client because the identification band is missing. Which of the following actions by the LPN is best? a) Have the roommate identify the client b) Ask the client to state their full name c) Ask another LPN to identify the client d) Look at the photograph on the client's medical record

d

A client returns to the clinic 2 weeks after being started allopurinol 200 mg PO daily. The LPN reviews information about this medication with the client. Which of the following statements by the client indicates that the teaching was effective? a) "I should take my medication on an empty stomach" b) "I should take my medication with orange juice" c) "I should increase my daily intake of protein" d) "I should drink at least 8 glasses of water daily"

d Explanation: Allopurinol is an antigout agent that reduces uric acid. It can cause kidney stones therefore the client should drink at least 3000 mL/day to reduce the risk of renal calculi formation. It is not necessary to increase the intake of protein. Orange juice makes the urine acidic. Allopurinol is more soluble in alkaline urine. Allopurinol is best tolerated with or immediately after meals to reduce GI irritation.

The LPN is implementing care for an adolescent client diagnosed with anorexia nervosa. On admission, the girl weighs 82 lbs. and is 5'4" tall. Laboratory results indicate severe hypokalemia, anemia, and dehydration. The LPN should give which of the following nursing diagnosis is the highest priority? a) Body image disturbance related to weight loss b) Self-esteem disturbance related to feelings of inadequacy c) Impaired nutrition: less than body requirements related to decreased intake d) Deficient cardiac output related to the potential for dysrhythmias

d Explanation: Because the question asks for highest priority we can eliminate psychosocial answers. Physiological answers are higher priority. This leaves answers c and d. Dysrhythmias are a concern for a client with hypokalemia, which often occurs with anorexia nervosa. Deficient cardiac output is a higher priority than altered nutrition.

The LPN is caring for a client who underwent abdominal surgery 6 hours ago. Which of the following actions by the LPN is most important? a) Have the client use a pillow to splint the incision b) Instruct the client how to safely get out of bed c) Reinforce the dry dressing to provide more padding d) Turn the client to check for bleeding underneath the client

d Explanation: Bleeding is a risk for all surgical abdominal wounds. According to the nursing process you should collect data first. Eliminate a, b, and c which are implementation answers. Clients with abdominal surgical wounds often find their most comfortable position lying on their backs in bed. Fluid, namely blood, flows via gravity to dependent areas. A cursory look at the top may reveal no drainage; however when the client is rolled to the side, a pool of blood could be noted if the wound is hemorrhaging. Even if this had not occurred to you, you are still able to correctly answer this question using the data collection versus implementation strategy.

A client is being treated for Addison's disease. The primary health care provider orders cortisone 25 mg PO daily. The LPN should explain to the client that a dosage adjustment may be required in which of the following situations? a) Dosage is increased when blood glucose level increases b) Dosage is decreased when dietary intake is increased c) Dosage is decreased when infection stimulates endogenous steroid secretion d) Dosage is increased relative to an increase in the level of stress

d Explanation: Cortisone is a hormone from the adrenal glands. Cortisone is not related to insulin or diet. Answer c is incorrect because "endogenous" means within the client and because client is receiving the hormone it must mean they have adrenal insufficiency. Therefore infection can't stimulate steroid secretion. This is a process of elimination.

A child biking to school hits the curb, and then fell. The child tells the LPN "I think my leg is broken." Which of the following is the first action the LPN should take? a) Immobilize the affected limb with a splint and ask the client not to move b) Collect data of the circumstances surrounding the accident c) Place the client in a semi-fowlers position to facilitate breathing d) Check the appearance of the client's leg

d Explanation: Determine whether you should be collecting data or implementing. The child's statement alerts the LPN that there is a problem and the LPN should begin the steps of the nursing process. The first step is data collection. Eliminate answers a and c as they are implementation. Examination of the leg takes priority over investigation into what happened to cause the accident.

The primary HCP prescribed phenytoin 100 mg PO q.i.d. for the client. Prior to administering the second dose, the LPN observes that the client appears lethargic and has nystagmus and slurred speech. In addition to notifying the supervising RN, the LPN should do which of the following? a) Administer phenytoin to prevent and impending seizure b) Administer the phenytoin to prevent cardiac arrhythmia c) Withhold phenytoin due to signs of an allergic reaction d) Withhold the phenytoin because client show signs of toxicity

d Explanation: Lethargy, nystagmus, and slurred speech suggests phenytoin toxicity. This drug should be withheld.

The LPN is caring for a client several hours after application of a right lower extremity cast. The client reports "My right toes feel funny." What is the first action the LPN should take? a) Elevate the right leg on a pillow b) Administer an analgesic c) Reassure the client that tingling is normal d) Compare capillary refill of right and left toes

d Explanation: Possible decrease in circulation after cast application. The client is at risk for injury from compromised circulation. Eliminate psychosocial option c. Use the ABCs. By elevating the right leg, this would decrease circulation to that extremity, which is not a desired outcome. If an analgesic is administered it may alter some of the observations that indicate circulatory compromise. Prolonged capillary refill may indicate decreased blood flow to the right foot and toes. This is the correct choice.

A client reporting chest pressure is brought to the emergency department (ED). Vital signs include BP of 150/90 mm Hg, pulse is 88 bpm, respirations 20 breaths/min. The LPN administers nitroglycerin 0.4 mg sublingually as ordered. After five minutes the client's vital signs include BP of 100/60 mm Hg, pulse 96 bpm, respirations of 20 breaths/min. Which of the following actions should the LPN take next? a) Notify the primary health care provider of hypotension b) Place the client in semi-fowlers position and administer O2 at 4L/min c) Administer a second dose of nitroglycerin 0.4 mg sublingually, as ordered d) Document vital signs, and continue to monitor the client

d Explanation: Recognize the client's response as normal. The BP has decreased due to vasodilation. Decreased BP is expected. Respirations rate is stable and there is no indication of respiratory distress, so O2 is not necessary. The nurse should assess the client for chest pain first and then administer a second dose of medication only if the client continues to report chest pain.

The LPN is caring for a client diagnosed with Parkinson's disease. The LPN observes that the client has tremors of the hands and slurred speech. The family reports that the client appears depressed. What is the priority care for the client? a) Place a clock and calendar within the client's view within the room b) Encourage the client to perform range of motion exercises c) Ask the client's family about the client's favorite television show d) Encourage client to sit on the edge of bed before ambulation

d Explanation: Remember that physical and safety needs take priority over psychosocial needs. Clients diagnosed with Parkinson's disease are at risk for orthostatic hypotension due to autonomic dysfunction.

A client reports to the LPN " I just started to feel short of breath." The client has normal saline solution infusing at a rate of 75 mL/hour through a peripherally inserted central catheter (PICC). What is the first action the LPN should take? a) Obtain clients BP and apical heart rate b) Reassure client that shortness of breath will improve c) Observe the insertion site of the PICC d) Elevate the head of the bed 90 degrees

d Explanation: Rule out psychosocial answer (b). Apply ABCs. A) Obtaining BP is an appropriate action but not the first. Immediate action is needed. C) Observing the site of the PICC may show if infiltration or thrombophlebitis is present. D) Sitting in the upright position allows for increased chest expansion, and respiratory status improves.

The LPN is preparing a primigravid client for primary health care provider examination. Laboratory test results are available. Which fasting serum glucose level result would indicate that gestational diabetes is likely? a) Serum glucose level 40 mg/dL b) Serum glucose level of 100 mg/dL c) Serum glucose level of 140 mg/dL d) Serum glucose level of 180 mg/dL

d Explanation: Serum glucose level of 180 mg/dL: serum glucose level needs to be above 140 mg/dL to suggest gestational diabetes.

The LPN is assisting a client with ambulation when the client begins to fall. What is the most important action for the LPN to take? a) Grasp the client under the arms, bend at the waist, and assist the client to the floor. b) Place feet close together, place arms under the clients axillae, and slide the client to the floor. c) Place arms around the client's waist and assist the client to the closest chair or bed d) Place feet wide apart, push the pelvis forward, and slide the client down one leg.

d Explanation: The topic is client safety. Select the answer that best promotes client safety. Also consider appropriate body mechanics while assisting the client and protecting yourself from injury. A) Bending at the waist is an example of body mechanics that will increase risk of injury to the LPN. Grasping the client under the arms does not provide the greatest stability while assisting the client. B) This action increases the risk of injury to the LPN. The LPN should place feet wide apart to increase safety. C) This action increases the risk of injury to the client. It is more important to assist the client to a safe position than to place the client on a chair or bed. D) The outcome of this action is desired. The wide positioning of the feet and forward pelvis ensures stability. Sliding the client down the leg decreases the risk of injury to the client.

Two hours after the insertion of a Salem sump nasogastric (NG) tube, the client vomits a moderate amount of yellow-green fluid. What is the most important action for the LPN to take? a) Inject 30 mL air and auscultate the left upper quadrant b) Instill 20 mL carbonated beverage into drainage tube c) Inform the primary HCP of the vomiting d) Irrigate NG tube with 20 mL normal saline

d Explanation: Irrigation with NS is an appropriate standard of care, is a safe action, and may clear the obstruction.

The LPN is preparing to give an immobile client a bedpan. Arrange the following steps the the LPN should perform them. All options must be used. a) Cover the patient with bed linens for privacy b) Help lift the client by placing one hand under the client's lower back. c) Ask the client to flex the knees and raise the buttocks d) Put on a pair of clean examination gloves e) Raise the opposite side rail to prevent the client from falling out of the bed f) Place the bedpan on the bed so that the client's buttocks rest on the rim

d, e, c, b, f, a Put on pair of clean exam gloves Raise the opposite side rail to prevent the client from falling out of bed Ask the client to flex the knees and raise the buttocks Help lift the client by placing one hand under the client's lower back Place the bedpan on the bed so that the client's buttocks rest on the rim Cover the client with bed linens for privacy