Hurst 1

An unlicensed assistive personnel (UAP), assigned to take care of a client who is HIV positive, refuses the assignment, stating fear of personal injury. What action should the LPN/VN take first?

. Inform the UAP that refusing client care is not acceptable practice.

The nurse is cleaning and dressing a foot ulcer of a diabetic client. Which actions are appropriate?

. Wears sterile gloves to clean the ulcer. 3. Cleans ulcer with normal saline. 5. Cleans ulcer in a full circle, beginning in the center and working toward the outside.

An LPN/VN from the maternity unit is pulled to the medical-surgical unit for the first four hours of the shift. When the LPN/VN is receiving assignments from the charge nurse, which client assignment would be considered inappropriate?

Client diagnosed with Methicillin-Resistant Staphylococcus Aureus

Which interventions are most appropriate for the nurse to provide for the client diagnosed with late onset Alzheimer's disease?

2. Offer fluids every 2 hours during the day and restrict fluids after 6 pm. 5. Store frequently used items within easy reach of the client.

A client has an acute onset of fever, chills, and RUQ pain. The vital signs are: Temp 99.8°F (37.7°C), HR 132, RR 34, B/P 142/82. Arterial blood gas (ABG) results are: pH 7.53, PaC02 30, HCO3 22. The nurse determines that this client is in which acid base imbalance?

Respiratory alkalosis

A client diagnosed with hypothyroidism with myxedema is prescribed levothyroxine, which is to be taken in increasing dosages. Which finding, if present, indicates that the drug dosage is too high?

Angina and palpitations

The nurse is caring for a client while an antibiotic is being infused. The client reports burning at the intravenous (IV) site and the nurse notes that there is no blood return after lowering the IV bag. Which nursing intervention should the nurse implement?

Stop the infusion.

The nurse is providing care to a client who is infected with Clostridium difficile (C. diff). Which interventions will lessen the likelihood of transmission?

Use soap and water to perform hand hygiene Change gloves before touching non-contaminated articles. Place client in room with client who has the same microorganism.

.What important principle should the nurse reinforce with the client performing intermittent self-catheterization?

Is a clean procedure

Which nursing intervention should receive priority after a client has returned from having had eye surgery

Maintain head of bed at 35°

A renal transplant client has received discharge education. Which statement by the client indicates the need for follow up?

will be on steroids for 3 months, then I will not have to take them.

A client with Bell's palsy is having difficulty eating. Which action by the nurse will be most helpful?

Have the client chew food on the unaffected side of the mouth.

The nurse is helping a client to bed when the client begins having a generalized seizure. Which action should the nurse take?

Assist the client to the floor in a side-lying position.

Which menu selection by the client diagnosed with nephrotic syndrome indicates that reinforcement of dietary teaching was understood?

Scrambled eggs, sliced turkey, biscuit, whole milk

Which action by a new nurse indicates to the supervising nurse that the sterile field has been contaminated?

Places sterile gauze dressing within the one inch border of sterile field.

The nurse is caring for a client who is severely depressed and has an extremely low energy level. The client answers questions by using one or two words, and makes no eye contact. Which intervention is most appropriate for this client?

Sit with the client and make no demands.

Which tasks would be appropriate for the LPN/VN to accept from the RN?

Administer antibiotic via intravenous piggyback (IVPB). Check for urinary retention Remove wound sutures.

After the nurse administers ear drops to an adult client, it is important for the nurse to implement which action?

Gently massage the tragus of the ear.

Parents of school aged children are working toward a goal of healthy family TV viewing. Which parental statement indicates to the nurse an adequate understanding of appropriate use of TV in the family?

" don't allow my kids to watch violent TV shows".

A client recently prescribed propranolol returns to the outpatient clinic for follow-up. Which statement by the client should be reported immediately to the primary healthcare provider?

" feel a little short of breath when walking."

The nurse has been assisting a client to achieve relaxation using deep breathing exercises. What statement by the client requires follow up?

" will inhale slowly and deeply through my mouth and expand my chest."

An elderly client with vomiting and diarrhea for three days, is receiving IV fluids at 200 mL/hr via pump. What is the priority nursing action?

. Auscultate lungs every 2-4 hours.

After injecting enoxaparin subcutaneously into the abdomen, which action should the nurse take?

Remove the needle and engage the needle safety device

Which data will provide the nurse with the most information regarding a client's neurologic function?

1. Level of consciousness 5. Verbal ability

Which task would be appropriate for the LPN to accept from the charge nurse?

Changing a colostomy bag.

The client needs assistance to apply anti-embolism stockings each day in the long-term care facility. Today, as the nurse enters the room to apply the stockings, she finds that the client has been walking about the unit for 30 minutes. What should the nurse do first to lessen the risk of swelling of the lower extremities?

. Elevate the extremities in bed for 30 minutes before application.

A client diagnosed with cancer has been losing weight. How should the nurse reinforce teaching for the client regarding methods for improving nutritional status to maintain weight?

1. Add butter to foods. 3. Add powdered creamer to milkshake. 4. Use biscuits to make sandwiches. 6. Put honey on top of hot cereal.

Which interventions are appropriate for the nurse to initiate for a client post liver biopsy?

1. Apply direct pressure to site immediately after needle is removed. 2. Monitor puncture site every 15 minutes for 1 hour. 5. Advise client that pain may occur as the anesthetic wears off.

A client is admitted with a diagnosis of myasthenia gravis. What nursing interventions will assist in managing the client's swallowing and chewing impairment?

1. Provide foods that are soft and tender. 2. Allow client to rest between bites. 3. Encourage client to drink thickened liquids.

A home care nurse is visiting a client who delivered her first baby one week ago. What behavior by the client would indicate to the nurse that maternal-infant bonding is occurring?

1. Holds baby face to face 2. Talks about the baby's features 3. Touches baby frequently 4. Talks to baby

Which client assignments would be appropriate for the LPN/VN to accept from the charge nurse?

1. In Bucks traction requiring frequent pain medication. 2. Twenty four hours post appendectomy. 3. Diagnosed with cholelithiasis and scheduled for surgery in the AM.

A nurse enters a client's room to find the client on the floor having a grand mai seizure. What action should the nurse take?

Place a towel or sheet under the client's head.

.When reinforcing teaching, what symptom would the nurse include as being the most common initial visual change associated with glaucoma?

Progressive tunnel vision occurs.

The nurse is providing care to a 5 year old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client?

Provide distraction by asking the client to sing with the nurse.

A new admit arrives to the nursing unit with one thousand dollars in cash. What would be the best action by the nurse to safeguard the client's money?

Put itemized cash in envelope and place in hospital safe

Which components of the communication cycle should the nurse include as necessary for effective verbal communication?

A clear message is formulated. There is a sender for every message There is a receiver for every message.

The nurse is caring for a client with decreased cardiac output secondary to heart failure with fluid volume overload. Which signs/symptoms are an indication to the nurse that treatment has not been effective?

2. Dyspnea on exertion 3. Persistent cough 5. Heart rate irregular at 118/m

Which tasks can the LPN/LVN assign to an unlicensed assistive personnel (UAP)?

2. Obtain blood pressure of client diagnosed with nephrotic syndrome. 4. Document the intake and output of a client in acute renal failure. 6. Perform perineal care of a client who has urinary incontinence.

A busy LPN instructs an unlicensed assistive personnel (UAP) to obtain daily weights on a client. The LPN provides initial direction for the task, monitors that the task is successfully completed, reviews the results of the daily weight, and reports the results to the RN. Which action has the LPN taken?

3. Appropriately assigned a client care task. 4. Supervised the performance of a client care task.

A registered nurse (RN) is delegating nursing activities to a licensed practical nurse (LPN) on a medical-surgical unit. If assigned by the RN, which activities can the LPN legally perform?

Blood glucose testing Intramuscular injection

The client expresses concern to the nurse about the ability to provide self-care and perform activities of daily living at discharge. Which member of the healthcare team should the nurse contact to provide information and assist the client with resources for an effective discharge plan?

Case manager

A client is admitted with an acute episode of diverticulitis. What symptom would the nurse promptly report to the primary healthcare provider?

Abdominal rigidity with pain in the left lower quadrant

What discharge instructions should the nurse reinforce to the client post abdominal hysterectomy?

Ambulate at least 3-4 times per day. Notify the primary healthcare provider of a yellow discharge from the surgical wound. Press a pillow over incision when coughing to ease discomfort.

A client recently diagnosed with diabetes is sent home with a prescription for subcutaneous insulin. What information is essential for the nurse to emphasize concerning safe needle disposal?

Any hard plastic container with a screw-on cap may be used.

Which task would be appropriate for the LPN/VN to accept from the charge nurse?

Collect data on a new client admit. Bolus feeding a client who has a gastrostomy tube. Reinserting a nasogastric tube (NG) that a client accidentally pulled out. Monitor patient control analgesic (PCA) pump pain medication being delivered to

A client diagnosed with alcoholism was admitted to the medical unit with substance-withdrawal delirium. Two days later, the client decides to leave the hospital against medical advice. What action should the nurse take?

Determine why the client wants to leave

Which observation by the nurse would demonstrate normal development of an infant during a well child clinic visit?

Eleven month old infant who can only stand by holding onto the walls.

A client comes into the clinic for a routine check-up during the second trimester of pregnancy. The client reports gastrointestinal (GI) upset and constipation. The nurse reviews the client's medications. Which client medication is most commonly associated with Gl upset and constipation?

Ferrous sulfate

A primary healthcare provider has prescribed the insertion of a nasogastric (NG) tube. In what order should the nurse perform this procedure?

First, elevate the client's head of bed to Fowler's position. Second, measure the distal NG tube from the nose tip to the earlobe to the xiphoid process. Third, lubricate 2-3 inches of the distal NG tube. Fourth, insert the NG tube into unobstructed naris. Fifth, advance NG tube upward and backward until resistance is met. Sixth, rotate catheter and advance into oropharynx. Seventh, have client swallow ice to pass the NG tube into the stomach. Eighth, secure the NG tube. The core issue of the question is knowledge of the insertion procedure for a nasogastric tube. Use nursing knowledge to sequence the steps that the nurse needs to take. Visualize the procedure to aid in answering the question.

Which menu selection by the client diagnosed with cholelithiasis indicates understanding of a proper diet

Grilled pork chops in peach sauce, baked sweet potato, sherbet

The nurse is caring for a client 28 weeks pregnant who reports swollen hands and feet. Which additional sign or symptom would cause the greatest concern?

Muscle spasms

A nurse is caring for a Mexican-American client post stroke. While in the client's room, a curandero visits at the request of client. What is the best action of the nurse?

Reinforce client care with the client and curandera

The nurse is caring for a client who has been in Russell's traction for four days. Which finding would require immediate action by the nurse?

Report of sharp pain to right upper anterior chest wall.

The nurse is reinforcing teaching to a client who has been prescribed fluticasone/salmeterol. What points are important for the client to understand?

Rinse mouth after medication administration to decrease infection. 3. Take this medication every day, even on days when breathing fine. 4. Administer by inhalation device twice daily. 5. Carry a rescue inhaler, such as albuterol, when leaving home.

The nurse is identifying home safety issues to prevent injury for a visually impaired elderly client who also has diabetes. Which findings are important for the nurse to include in this process?

Rugs secured to the floor Adequate lighting Functional eye glasses Client is wearing well-fitting closed toe shoes

A client who has schizophrenia tells the nurse, "I am Jesus and I am here to save the world". The client is warning others of hell and damnation. The whole unit is getting upset and several are beginning to cry. What action should the nurse take?

Set limits and send the client to room

The nurse is caring for a depressed client. The client has a flat affect, apathy, and slowed physical movement. The client has not bathed in several days and there is a malodorous odor noted. Which intervention would be most appropriate at this time?

Tell the client it is time to take a shower.

Which home routines help reduce the risk for skin damage in a client with impaired sensation?

Testing the water with the back of the wrist and forearm before getting in the shower. Wear shoes when out of bed

A frightened client comes to the nurses' station during the night and reports hearing the voice of the devil speaking to them. Which response by the nurse is priority?

What did the voice tell you?

A Hispanic client is considering treatment options for cancer. The client is reports needing to discuss the options with the sons before making a final decision. What should the nurse say to the client?

You are wanting your sons to assist you in deciding about treatment options