LPN Final

Which of the following is the best recommendations for a client with anemia to help reduce lethargy and fatigue? -Eat a balanced diet using the food guide pyramid. -Take frequent resting periods. -Take short walks twice a day. -Make sure to sleep for at least 8 hours every night.

-Take frequent resting periods.

The LPN is gathering data from a client who is being treated for obsessive-compulsive disorder (OCD). Which of the following is the MOST important question the LPN should ask this client? -"Do you experience feelings of panic in a closed area?" -"Do you have trouble controlling upsetting thoughts?" -"Do you find it hard to stay on task?" -"Do you find yourself forgetting simple things?"

-"Do you have trouble controlling upsetting thoughts?" One feature of OCD is the client's inability to control intrusive thoughts that repeat over and over.

A man calls the suicide preventions hotline and states that he is going to kill himself. Which of the following questions should the LPN ask FIRST? -"Do you want me to prevent you from killing yourself?" -"What happened to cause you to want to end your life?" -"How do you plan to kill yourself?" -"When did you start to feel as though you wanted to die?"

-"How do you plan to kill yourself?" Lets you prioritize interventions to assure safety

A client is admitted to the unit to rule out acute renal failure. The LPN would be MOST concerned if the client made which of the following statements? -"It is quite painful for me to urinate." -"I urinate in the morning and again before dinner." -"My urine is often pink-tinged." -"It is hard for me to start the flow of urine."

-"I urinate in the morning and again before dinner." Symptoms of acute renal failure include decreased urinary output, hypotension, tachycardia, lethargy, normal output is 1200-1500 mL a day or 50-63 mL/hr, normal voiding pattern is 5-6 times/day and once at night.

The nurse is caring for 4 clients with a metabolic disorder. After reviewing blood gas results, which client will the nurse see first? -pH of 7,36, HCO3 of 21, PaCO2 of 33 -pH of 7.33, HCO3 of 20, PaCO2 of 43 -pH of 7.46, HCO3 of 27, PaCO2 of 48 -pH of 7.43, HCO3 of 23, PaCO2 of 47

-pH of 7.33, HCO3 of 20, PaCO2 of 43 The client who needs to be seen is the one with uncompensated metabolic acidosis, the others are either partially compensated or compensated.

The nurse reinforces instruction to an older adult client with arthritis on the side effects of nonsteroidal anti-inflammatory drug (NSAID) therapy. Which client statement would indicate that teaching had been effective? -"If I have a change in my mood I will call the prescriber." -"I will report any abnormal bruising." -"Caffeine will decrease the effectiveness of the medication." -"I cannot take other medications."

-"I will report any abnormal bruising." Older adult clients are at risk for increased bleeding with nonsteroidal anti-inflammatory drug (NSAID) therapy. The client should be taught to report any abnormal bruising, which may indicate bleeding. Older adult clients often take several medications, and refraining from taking them with NSAIDs is an unrealistic outcome. Mood changes are not a side effect of NSAID therapy. There is no reason for avoiding use of caffeine while using an NSAID.

The LPN is caring for a client with hepatitis B. The client is to be discharged the next day. The LPN would be MOST concerned if the client made which of the following statements? -"I must not share eating utensils with my family." -"I'm glad that my husband and I can continue to have intimate relations." -"I must use my own bath towel." -"I must eat small, frequent feedings."

-"I'm glad that my husband and I can continue to have intimate relations." The client must avoid sexual contact until serologic indictors return to normal.

An elderly client is recently diagnosed with hypothyroidism. He lives in his own apartment in a community development designed for the elderly. He asks the nurse for advice about his condition. What is the best advice for the nurse to give the client? -"Keep the temperature in your apartment cooler than usual." -"Increase fiber and fluids in your diet." -"Stop attending group activities." -"Stop taking your self-prescribed daily aspirin."

-"Increase fiber and fluids in your diet." Clients with hypothyroidism typically have constipation. A diet high in fiber and fluids can help prevent this. The client doesn't need to stop all group activities, although he may need to limit them until his condition improves. Taking aspirin isn't related to hypothyroidism management and does not interfere with treatment. Clients with hypothyroidism have an intolerance to cold and need an environment warmer than average.

The LPN is assisting with discharging a client from an inpatient alcohol treatment unit. Which of the following statements by the client's wife indicate that the family is coping adaptively? -"My husband will do well as long as I keep him engaged in activities that he likes." -"My focus is learning how to live my life." -"I am so glad that our problems are behind us." -"I'll make sure that the children don't give my husband any problems."

-"My focus is learning how to live my life." This statement reflects the wife is accepting responsibility for codependent behavior.

An LPN is caring for clients in the mental health clinic. A woman comes to the clinic reporting insomnia and anorexia. The client tearfully tells the LPN that she was laid off from a job she had held for 15 years. Which of the following responses by the LPN is MOST appropriate? -"Did your company give you a severance package?" -"Focus on the fact that you have a healthy happy family" -"Tell me what happened." -"Losing a job is common nowadays."

-"Tell me what happened." The open ended statement explores the situation and allows the client to verbalize his feelings.

The nurse reinforces medication instructions to a client with peptic ulcer disease. Which statement by the client indicates the best understanding of the medication therapy? -"Omeprazole will coat the ulcer and help it heal." -"The nizatidine will cause me to produce less stomach acid." -"Sucralfate will change the fluid in my stomach." -"Antacids will coat my stomach."

-"The nizatidine will cause me to produce less stomach acid." Nizatidine, a histamine H2-receptor blocker, is frequently used in the management of peptic ulcer disease. Histamine H2-receptor blockers decrease the secretion of gastric acid (HCL). Antacids are used as adjunct therapy and neutralize acid in the stomach. Omeprazole is a proton pump inhibitor. Sucralfate promotes healing by covering the ulcer, thus protecting it from erosion caused by gastric acids.

The LPN plans to administer furosemide 20 mg to a client diagnosed with renal failure. The client asks the LPN why he is receiving this medication. Which of the following responses by the LPN is BEST? -"To decrease your circulating blood volume." -"To increase the workload on your heart." -"To increase excretion of sodium and water." -"To decrease the blood flow to your kidney"

-"To increase excretion of sodium and water." The primary reason for giving furosemide is to augment the kidney's functioning and it does this by inhibiting sodium and chloride reabsorption at the proximal and distal tubules and the ascending loop of Henle.

A female client visits the clinic reporting right calf tenderness and pain. It would be MOST important for the LPN to ask which of the following questions? -"Have you had any fractures in the last year?" -"Do you exercise excessively?" -"Are you under a lot of stress?" -"What type of birth control do you use?"

-"What type of birth control do you use?" There is increased risk for DVT with oral contraceptives.

State law requires that all clients at an extended stay facility be tested for tuberculosis exposure. The purified protein derivative (PPD) is administered to the clients by the LPN. Which of the following represents an appropriate time for the results of this test to be checked following administrations? -4 hours -Two weeks -48 hours -One week

-48 hours The test is read 48-72 hours after injection.

The weight of a just-delivered newborn is 3050 grams. The LPN would convert this weight to pounds (lbs) to announce the baby's weight to the parents. The newborn's weight in pounds is? -5.11 lbs -6.7 lbs. -6.2 lbs -5.7 lbs

-6.7 lbs. 1,000 grams= 1 kg 3050 g/1000 = 3.05 kg 1 kg = 2.2 lbs 3.05 kg x 2.2 lbs= 6.7 lbs.

The LPN knows that a client who takes which medication is most at risk for developing an infection? -Metoprolol -Alprazolam -Phenytoin -Prednisone

-Prednisone Prednisone is a medication used for many things including decreased inflammatory response and immunosuppression, when a client takes this medication the risk for infection increases.

The LPN is caring for 4 clients who have diabetes mellitus. At the beginning if the shift, which client should the LPN see first? -A 7-year-old client with Type 1 diabetes mellitus and blood sugar level of 99 -A 58-year-old client with Type 2 diabetes mellitus and a blood sugar level of 220 -A 17-year-old client with Type 1 diabetes mellitus and a blood sugar level of 43 -A 75-year-old client with type 2 diabetes mellitus and a blood sugar level of 175

-A 17-year-old client with Type 1 diabetes mellitus and a blood sugar level of 43 It is important to attend to the client with hypoglycemia first because its onset is rapid and it can progress to unconsciousness and seizures shortly after the onset of symptoms.

The LPN is caring for clients on the surgical floor and has just received report from the RN. Which of the following clients should the LPN see FIRST? -A 43-year-old who had a mastectomy 2 days ago; 23 mL of serosanguinous fluid noted in the Jackson-Pratt drain. -A 59-year-old with a collapsed lung due to an accident; no drainage noted in the previous 8 hours. -A 62-year-old who had an abdominal perineal resection 3 days ago; client reports chills. -A 35-year old admitted 3 days ago with a gunshot wound; 1.5 cm area of dark drainage noted on the dressing.

-A 62-year-old who had an abdominal perineal resection 3 days ago; client reports chills. This client is at risk for peritonitis and should be assessed for further symptoms of infection.

The LPN is caring for clients in the outpatient clinic. Which of the following clients should the LPN see FIRST? -A client with Hepatitis A who states, "My arms and legs are itching." -A client with osteomyelitis of the spine who states, "I am nauseous that I can't eat." -A client with rheumatoid arthritis who states, "I am having trouble sleeping." -A client with a cast states, "I have a funny feeling in my right leg."

-A client with a cast states, "I have a funny feeling in my right leg." The may indicate neurovascular compromise which requires immediate data collection.

The LPN has just received report for the upcoming shift and plans to visit which client first? -A client with influenza who is complaining of shortness of breath. -A client with COPD with a peripheral oxygen saturation of 89% -A client with pleurisy who is complaining of chest pain. -A client with pneumonia who has a temperature of 101.5

-A client with influenza who is complaining of shortness of breath. The nurse must first assess any client with a condition that could be life threatening. A client with influenza who is experiencing shortness of breath needs to be assessed immediately to determine the problem. Chest pain is expected to be experienced in a client with pleurisy, a fever is common in pneumonia.

The LPN observes activities on a medical/surgical unit. The LPN should intervene if which of the following is observed? -A client's wife disposes of her husband's used tissues in the bedside container before opening the roommates milk carton. -An LPN puts gown, gloves, mask, and goggles on prior to inserting a nasogastric tube. -An NAP removes her gloves and washes her hands for 15 seconds after emptying an indwelling urinary catheter. -A visitor talks with a client diagnosed with MRSA wound infection while he eats his lunch.

-A client's wife disposes of her husband's used tissues in the bedside container before opening the roommates milk carton. Contaminated hands cause cross-infections, instruct family about when handwashing is necessary and the correct procedure.

The LPN is assisting a quadriplegic client with passive ROM exercise. The LPN moves the client's left leg away from the midline of the body. Which of the following ROM exercises is this an example of? -Abduction -Eversion -Pronation -Adduction

-Abduction Movement away from the body is called abduction. Adduction is movement toward the midline of the body. Pronation is rotation of the forearm so the palm of the hand is down Eversion is a movement that turns the sole of the foot outward.

An experienced LPN/ LVN, under the supervision of the team leader RN, is providing nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN? (Select all that apply.) -Administering medications via metered-dose inhaler (MDI) -Auscultating breath sounds -Developing the nursing care plan -Checking oxygen saturation using pulse oximetry -Completing in-depth admission assessment

-Administering medications via metered-dose inhaler (MDI) -Auscultating breath sounds -Checking oxygen saturation using pulse oximetry The experienced LPN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/ LVN. Independently completing the admission assessment, developing the nursing care plan is within the scope of the RN.

The LPN is caring for a client who states, "I just want to die." The LPN should examine the client's medical record for which of the following documents? -"Do not resuscitate" order -Power of Attorney -Advance Directives -Living Will

-Advance Directives Advance Directives specify the client's wishes regarding health care decisions.

The nurse knows that it is best to use soap and water for hand hygiene instead of hand sanitizer in which situation? -Before assisting a client to bed -After obtaining a urine specimen -After administering an oral medication -Before putting on glove.

-After obtaining a urine specimen Soap and water is used when there is visible soil on the hands and when in contact with body fluids. Hand sanitizer is used at all other times.

The nurse is caring for a female client who had developed a vaginal yeast infection as a result of treatment with which other medication? -Nadolol -Reserpine -Buspirone -Amoxicillin

-Amoxicillin Antibiotics can cause a vaginal yeast infection because they destroy colonies of normal vaginal flora, allowing the harmful microbes to thrive.

The LPN cares for a group of residents in a dependent living facility. The LPN determines which of the following clients is MOST at risk to develop pneumonia? -An 80-year-old female who walks 1 mile every day and has a history of depression. -A 72-year-old female with left-sided hemiplegia after a cerebrovascular accident. -An 87-yer-old male who smokes and has a history of lung cancer. -A 76-year-old male with a history of hypertension and Type 2 diabetes

-An 87-yer-old male who smokes and has a history of lung cancer. Advanced age, smoking, underlying lung disease, malnutrition and bedridden status are risk factors for developing pneumonia.

The licensed practical nurse (LPN) is reassigned to work on an acute care unit. Which of these clients would be most appropriate for the LPN to accept? -A confused client whose family complains about the nursing care given after the client's surgery -A client, admitted for a possible stroke, with unstable neurological findings -An older adult client diagnosed with cystitis who has an indwelling urethral catheter -A trauma victim with multiple lacerations requiring complex dressings

-An older adult client diagnosed with cystitis who has an indwelling urethral catheter LPNs who are reassigned to work on a different unit should be assigned to clients who are stable. The older adult diagnosed with cystitis is the most stable and the outcomes for care are fairly predictable. The other clients have more complex problems, as well as a higher risk for instability. LPNs should not accept an assignment that is beyond their knowledge or skills.

A client with a DNR (do not resuscitate) physician's order experiences a cardiac arrest. Which of the following is the FIRST action the LPN should take? -Summon the emergency code team. -Assess the client for signs of death. -Administer lifesaving medications -Open the airway and give 2 breaths

-Assess the client for signs of death. The client has signs of death and requires further assessment to confirm that the client is indeed dead.

A client is in the physical therapy room and tells the LPN/VN, "I feel like I'm going to have a seizure." Which intervention is most appropriate for the nurse to implement first? -Stay with the client and document observations -Reduce the noise and dim the lights in the room -Assist the client to a safe position away from hazards -Instruct a coworker to notify the registered nurse (RN)

-Assist the client to a safe position away from hazards Clients with seizure disorders (or epilepsy) often experience symptoms that warn them that a seizure is going to happen, called an aura. The most important action to implement in this situation is to place the client in a safe position so that if a seizure occurs, the client will not be injured. The LPN/VN should stay with the client and send someone to notify the RN (who can bring medication to prevent seizure activity). Noise reduction and light dimming may be beneficial in preventing an impending seizure, but they are not the priority. Remember to consider safety first when there isn't an immediate physical need.

The client, who is diagnosed with dementia, wanders throughout the long-term care facility. How can the nurse best ensure the safety of a client who wanders? -Frequently reorient the client to time, person, place -Explain the risk of walking with no purpose -Attach a monitoring band to the client's wrist -Apply a restraint to keep keep the client in a chair when awake

-Attach a monitoring band to the client's wrist A wander management system is used to give people with dementia and other "at risk" clients the ability to move freely where they live. The sensor in the bracelet trips an alarm that's attached to exterior doors if the client attempts to leave the facility. It is inappropriate to use restraints or other restrictive devices to keep clients in chairs or beds (unless they are potentially harmful to themselves or others.) Reality orientation is inappropriate for someone with dementia.

The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which outcome? -Suggestive of anemia -Common -Characteristic of a thrush infection -Indicative of a need to improve oral hygiene

-Characteristic of a thrush infection Candidiasis is a fungal infection caused by Candida albicans. When it occurs in the mouth, it is called thrush and appears as white plaques. Although it can occur in an immunocompromised client, it is not considered to be common

A nurse is reviewing the bowel prep using polyethylene glycol (GoLYTELY) with a client scheduled for a colonoscopy. Which of the following information should the nurse include? -The bowel prep will not begin acting until the day after it is consumed. -Check with the provider about taking current medications when consuming bowel prep. -Consume a normal diet until starting the bowel prep. -The bowel prep may be discontinued once feces start to be expelled.

-Check with the provider about taking current medications when consuming bowel prep. Some medications may be withheld when taking GoLYTELY due to their lack of absorption. This should be discussed with the provider. The client is instructed to consume a clear liquid diet prior to starting the bowel prep. The actions of GoLYTELY begin within 2 to 3 hr after consumption. The client is instructed to consume the full amount prescribed.

A client with a history of alcohol use disorder is transferred to the unit in an agitated state. He is vomiting and diaphoretic. He says he had his last drink 5 hours ago. The LPN would expect to administer which of the following medications? -Disulfiram -Chlordiazepoxide hydrochloride -Methadone hydrochloride -Naloxone hydrochloride

-Chlordiazepoxide hydrochloride Chlordiazepoxide hydrochloride (Librium) is an antianxiety medication used to treat symptoms of acute alcohol withdrawal, side effects are lethargy, hangover, agranulocytosis

The LPN is named in a lawsuit. Which of these factors will offer the best protection for the nurse in a court of law? -Sworn statement that health care provider orders were followed -Complete and accurate documentation of assessments and interventions -Clinical specialty certification by an accredited organization -Above-average performance reviews prepared by nurse manager

-Complete and accurate documentation of assessments and interventions The medical record is a legal document. Documentation should include all steps of the nursing process; it must be complete, accurate, concise and in chronological order. Inaccurate or incomplete documentation will raise red flags and may indicate the nurse failed to meet the standards of care. The attorney will review the medical record with the nurse before giving a deposition (sworn pretrial testimony.) Above-average performance reviews could be considered supporting information. Certification is an "extra" based on the nurse's initiative; it is, however, unrelated to accurate charting.

A client with chronic kidney disease is receiving ferrous sulfate. The nurse should monitor the client for which common side effect associated with this medication? -Constipation -Diarrhea -Weakness -Headache

-Constipation Ferrous sulfate is an iron supplement used to treat anemia. Constipation is a frequent and uncomfortable side effect associated with the administration of oral iron supplements. Stool softeners are often prescribed to prevent constipation.

The nurse is caring for a client newly diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following exercises is most appropriate for this client? -Intercostal muscle expansion exercises -Isometric leg exercises -Lumbar sacral strengthening exercises. -Diaphragmatic and pursed-lip breathing exercises.

-Diaphragmatic and pursed-lip breathing exercises. Clients with COPD are taught to use their diaphragmatic muscles, not their intercostal muscles, to breathe. Because of air trapping due to COPD, pursed-lip breathing exercises are indicated to help expel carbon dioxide. These exercises increase expiratory time, decrease expiratory rate, and increase tidal volume. Isometric leg exercises and lumbar sacral strengthening exercises don't improve breathing but may be important for general health.

The nurse has reinforced instructions to a client with tuberculosis about proper handling and disposal of respiratory secretions. The nurse determines that the client understands the instructions if the client verbalizes to take which measure? -Turn the head to the side if coughing or sneezing. -Discard used tissues in a plastic ba -Brush teeth and rinse the mouth once a day. -Wash hands at least four times a day.

-Discard used tissues in a plastic ba Used tissues are discarded in a plastic bag, so contaminated respiratory secretions can be contained. The client with tuberculosis should wash hands carefully after each contact with respiratory secretions. Oral care should be performed more than once a day. The client should be instructed to cover the mouth and nose when laughing, sneezing, or coughing and to wear a mask when in contact with others until drug therapy suppresses the infection.

A woman is hospitalized with a diagnosis of bipolar disorder. While she is in the client activities room on the psychiatric unit, she flirts with male clients and disrupts unit activities. Which of the following approaches would be MOST appropriate for the LPN to take at this time? -Distract the client and escort her back to her room. -Tell the client that she is behaving inappropriately and send her to her room. -Instruct the other clients to ignore this client's behavior. -Set limits on the client's behavior and remind her of the rules.

-Distract the client and escort her back to her room. Avoid confrontational interaction, ensure safety--distraction is a nonthreatening action and bipolar clients are easily distracted.

Which of the following should be initiated for a client suspected of having meningitis? -Airborne precautions -Droplet precautions -Contact precautions -Standard Precautions

-Droplet precautions Most forms of meningitis are transmitted from the secretion droplets of those who are infected.

A client with emphysema becomes restless and confused. Which of the following actions should the LPN take next? -Assess the client's potassium level. -Increase the client's oxygen flow rate to 5L/min. -Check the client's temperature. -Encourage the client to perform pursed-lip breathing.

-Encourage the client to perform pursed-lip breathing. Pursed lip breathing prevents collapse of the lung unit and helps client control rate and depth of breathing.

A client with a diagnosis of delirium is admitted to the hospital. To evaluate the cause of the client's delirium, blood is sent to the lab for analysis. The results are as follows: Na 156, Cl 100, K 4.0, HCO3 21, BUN 86, glucose 100. Based on these laboratory results the LPN would expect to see which of the following nursing diagnosis on the client's care plan? -Alteration in patterns of urinary elimination -Self-care deficit: feeding -Fluid volume deficit -Nutritional deficit: less than body requirements

-Fluid volume deficit Elevated Na+, decreased HCO3, elevated BUN = fluid volume deficit, other values are normal, elevated Na+ and BUN are seen with dehydration.

A nurse is caring for a client who has dyspnea. In which of the following positions should the nurse place the client? -Fowler's -Dorsal recumbent -Lateral -Supine

-Fowler's Fowler's position facilitates maximal lung expansion and thus optimizes breathing.

Following a colonoscopy, the physician restricts the client to a clear liquid diet. Which of the following would be included as an allowed food for this diet? -Pudding -Orange Juice -Gelatin -Ice Cream

-Gelatin Clear liquids include any food or drink that liquifies at room temperature and is transparent.

The LPN provides care to clients in a long-term facility. 4 meal choices are available to the clients. The LPN should ensure that a client on a low-cholesterol diet receives which of the following meals? -Egg custard and boiled liver. -Fried chicken and potatoes. -Grilled founder and green beans. -Hamburger and French fries.

-Grilled founder and green beans.

Mrs. Fischer's physician diagnosed that she has rheumatoid arthritis. With this condition, the client's chief complaint is persistent joint pain and stiffness. Pain and stiffness associated with RA is most often first noticed in the joints of which of the following? -Neck -Hands -Legs -Arms

-Hands Clients with RA usually experience discomfort in the proximal finger joints of the hands before any other joints of the body.

A client is brought to the ER bleeding profusely from a stab wound in the left chest area. The client's vital signs are blood pressure 80/50, pulse 110, and respirations 28. The LPN should expect which of the following potential problems? -Septic shock -Hypovolemic shock -Neurogenic shock -Cardiogenic shock

-Hypovolemic shock Loss of circulatory volume is hypovolemic shock, Cardiogenic is likely from MI or CHF, Neurogenic likely from spinal anesthesia or spinal cord injury, septic infection.

The physician orders packing for a nonhealing open surgical wound. Which of the following is the FIRST action by the LPN? -Plan to set up for clean technique -Observe for wound drainage or discharge. -Select the proper dressing material. -Identify the wound size shape, and depth.

-Identify the wound size shape, and depth. It is necessary to observe the wound to adequately prepare for a dressing change and select appropriate dressing materials.

A nurse is collecting data from a client who has experienced a left-hemispheric stroke. Which of the following is an expected finding? -Poor judgment -Impulse control difficulty -Inability to recognize familiar objects -Loss of depth perception

-Inability to recognize familiar objects A client who has experienced a right-hemispheric stroke will experience difficulty with impulse control. A client who has experienced a right-hemispheric stroke will experience poor judgment. A client who experienced a left-hemispheric stroke will demonstrate the inability to recognize familiar objects, also known as agnosia. A client who experienced a right-hemispheric stroke will experience a loss of depth perception.

A child is admitted with a diagnosis of suspected meningococcal meningitis. Which admission orders should the nurse implement first? -Monitor and record vital signs every 30 minutes -Initiate seizure precautions -Notify RN of changes in neurologic status -Initiate droplet precautions

-Initiate droplet precautions Meningococcal meningitis is an infection caused by the bacteria Neisseria meningitis. The first action for nurses to take is to initiate droplet precautions. The initial therapeutic management of acute bacterial meningitis includes droplet precautions, anti-infective therapy (a cephalosporin or penicillin), monitor neurological status along with vital signs, institute seizure precautions, and maintain optimum hydration.

The LPN is inserting an indwelling catheter. The catheter was inserted into the urinary meatus, and urine is flowing through the catheter tubing. Prior to inflating the balloon, which of the following steps should be performed? -Pull the catheter out 1-2 centimeters. -Insert the catheter an additional 1-2 inches. -Anchor the catheter to the client's thigh. -Irrigate the bladder with 10 mL of sterile water.

-Insert the catheter an additional 1-2 inches. Prior to inflating the balloon of an indwelling catheter, the catheter should be inserted 1-2 inches beyond the point at which urine is seen flowing, this prevents balloon inflation in the urethra which could cause damage to the urinary structure.

The LPN is reinforcing discharge teaching for client with Parkinson's disease. To maintain safety, the LPN should make which of the following suggestions to the family? -Obtain a hospital bed. -Perform an exercise program during the late afternoon. -Instruct the client to hold his arms in a dependent position when ambulating. -Install a raised toilet seat.

-Install a raised toilet seat. This will help the client to be independent.

The nurse is caring for an older client who is terminally ill. Which signs indicate to the nurse that death may be imminent? -Presence of swallowing reflex and active bowel sounds -Flushed and warm skin -Eupnea and normal body temperature -Irregular, noisy breathing and cold, clammy skin

-Irregular, noisy breathing and cold, clammy skin The clinical signs of impending or approaching death include inability to swallow; pitting edema; decreased gastrointestinal and urinary tract activity; bowel and bladder incontinence; loss of motion, sensation, and reflexes; cold or clammy skin; cyanosis; lowered blood pressure; noisy or irregular respiration; and Cheyne-Stokes respirations.

Which of the following actions by the LPN would be MOST helpful in preventing injury to elderly clients in a health care facility? -Closely monitor the temperature of hot oral fluids. -Maintain the safe function of all electrical equipment. -Use safety protective caps on all medications. -Keep unnecessary furniture out of the way.

-Keep unnecessary furniture out of the way. Falls are the most common cause of injury, and maintaining an uncluttered environment can help prevent falls.

A client is admitted to the unit reporting nausea, vomiting and abdominal pain. He is a Type 1 diabetic (IDDM). Four days earlier, he reduced his insulin dose when flu symptoms prevented him from eating. The LPN observes the client and finds poor skin turgor, dry mucous membranes, and fruity breath odor. The LPN should be alert for which of the following problems? -Ketoacidosis -Hyperglycemic hyperosmolar nonketotic coma -Viral illness -Hypoglycemia

-Ketoacidosis The cause of ketoacidosis is insufficient insulin, symptoms are polyuria, polydipsia nausea and vomiting, dry mucous membranes, weight loss, abdominal pain, hypotension shock and coma.

The physician orders an Ace bandage wrap for a client's left leg from toes to mid-thigh. The LPN should do which of the following? -Leave a small distal part of the extremity exposed -Increase friction between the skin and bandage surfaces. -Position the left leg in abduction. -Use multiple pins to secure the bandage.

-Leave a small distal part of the extremity exposed The enables the LPN to determine the circulation movement and sensation of a distal body part.

The nurse providing care to a client whose medication therapy for the treatment of renal calculi has failed. Based on this data, which treatment option does the nurse anticipate for this client? -Lithotripsy -Initiation of IV fluids -Dietary control -Surgical removal

-Lithotripsy When medication fails to dissolve stones, the preferred method of treatment is lithotripsy, which is using sound waves to crush the stones so they can be passed out of the urinary system. Depending on the location of the stones, surgery may be the next step in the treatment process. Diet and fluids are used to prevent further stone formation.

A client with diabetes mellitus who has been controlled with daily insulin has been placed on atenolol for the control of angina pectoris. Because of the effects of atenolol, the nurse determines that which is the most reliable indicator of hypoglycemia? -Low blood glucose -Tachycardia -Nervousness -Sweating

-Low blood glucose β-Adrenergic blocking agents, such as atenolol, inhibit the appearance of signs and symptoms of acute hypoglycemia, which would include nervousness, increased heart rate, and sweating. Therefore, the client receiving this medication should adhere to the therapeutic regimen and monitor blood glucose levels carefully. Low blood glucose is the most reliable indicator of hypoglycemia.

Which of the following actions by the LPN would be considered negligence? -Lowering the bed side rails after administering meperidine and hydroxyzine to a client preoperatively. -Crushing furosemide and adding to a teaspoon of applesauce for an elderly client. -Placing a used syringe and needle in a sharps container in a client's room. -Administering subcutaneous heparin into a client's abdomen without first aspirating blood.

-Lowering the bed side rails after administering meperidine and hydroxyzine to a client preoperatively. Bedside rails should always be raised after administration of preoperative medication.

The physician prescribes atorvastatin (Lipitor) for a client with elevated cholesterol levels that have not been sufficiently reduced with lifestyle changes. The LPN reinforces teaching about this medication to the client. Which of the following would the LPN explain as a potential side effect of taking this medication? -Anemia -Drowsiness -Muscle Pain -Confusion

-Muscle Pain

To enhance the percutaneous absorption of Nitroglycerin ointment, it would be MOST important for the LPN to select a site that is which of the following? -Near the heart -Muscular -Non-hairy -Over a bony prominence

-Non-hairy Skin site free of hair will increase absorption, avoid distal part of extremities dues to less than maximal absorption.

A licensed practical nurse (LPN) is having difficulty reading a health care provider's written order from the prior shift. What action should the nurse take? -Contact the manager to report the problem with the legibility of the order -Leave the order for the oncoming staff to follow up or interpret -Call the pharmacy for assistance in the interpretation -Notify the health care provider for clarification

-Notify the health care provider for clarification The nurse should clarify the order with the person who wrote the illegible or confusing order. If the PN reports to an RN, then the RN should obtain written clarification. In some states PNs may write verbal or telephone orders and in other states this is not allowed by the state's nurse practice act.

The LPN is preparing for graduation. What document can LPN's look to for the rules and regulations that define this license's scope of practice? -Nursing Textbooks -MSDS Unit Resource -Nurse practice Act -Policy and Procedures Manual

-Nurse practice Act The state Boards of Nursing within each state are responsible for formulating the state's Nurse Practice Act, which documents the scope of practice for each type of nursing license.

A client has adamantly refused all hygiene measures over the last 3 days. The LPN and the client are finally able to collaborate to achieve the hygiene goal of "self-administration of a complete bath once a day while in the hospital" To evaluate if this goal was met, the LPN should do which of the following? -Bathe the client to be sure the hygiene goal is met. -Observe the client performing portions of his daily bath. -Ask the client if he has performed his daily bath. -Remind the client to take his bath, providing the needed supplies.

-Observe the client performing portions of his daily bath. Direct observation provides the LPN with objective measurable data that the client has met the goal.

A client begins to breathe very rapidly. Which of the following actions by the LPN would be the MOST appropriate? -Notify the physician. -Obtain an oxygen saturation. -Measure blood pressure and pulse. -Assess the apical pulse

-Obtain an oxygen saturation. Provides the LPN with data about the client's oxygen saturation.

The physician orders ferrous sulfate (Feosol) 1 tablet P.O tid for a client with iron deficiency anemia. Based on what the LPN knows about the absorption of this medication, the best time for administration would be which of the following? -With meals -At regularly scheduled intervals -One hour before meals. -One hour after meals.

-One hour before meals. Iron is most effectively absorbed I administered 1 hour before or 2 hours after meals.

A nurse is caring for a an older adult client who has diabetes mellitus. The client reports loss of peripheral vision. For which of the following is the client at risk? -Cataracts -Macular degeneration -Angle-closure glaucoma -Open-angle glaucoma

-Open-angle glaucoma A client who has cataracts experiences a decrease in vision and sensitivity to lights. The nurse should anticipate that the client is experiencing open-angle glaucoma. Loss of peripheral vision is a clinical manifestation associated with this diagnosis. A client who has macular degeneration experiences a loss of central vision. A client who has angle-closure glaucoma experiences nausea and severe pain.

To determine the structural relationship of one hospital department with another, the LPN should consult which of the following? -Personnel Policies -Policies and Procedures Manual -Organizational Chart -Job Description

-Organizational Chart The organizational chart delineates the overall organization structure, showing which departments exist and their relationships with one another both laterally and vertically.

In order to evaluate the effectiveness of a client's heparin therapy, the LPN should monitor which of the following laboratory values? -Partial Prothrombin time -Platelet count -Prothrombin time -Bleeding time

-Partial Prothrombin time Partial Prothrombin time is the correct lab for Heparin, platelets evaluate platelet production bleeding time just detects platelet and vascular problems not altered., Prothrombin time used to monitor Coumadin therapy.

The nurse administers an injection to a client with a diagnosis of acquired immunodeficiency syndrome (AIDS). After administering the medication, the nurse should dispose of the used needle by which method? -Recapping the needle before placing it in a puncture-resistant container -Asking the client to recap the needle -Placing the needle and syringe in a puncture-resistant container -Laying the needle and syringe on the bedside table and carefully recapping the needle

-Placing the needle and syringe in a puncture-resistant container The correct procedure for needle disposal is to discard uncapped needles and sharps in a hard-walled, puncture-resistant, leak-proof container immediately after use. Discarding the uncapped needle and attached syringe in a designated sharps container prevents injury to the client and health care personnel. Recapping needles increases the risk of needle-stick injury.

A nurse in a clinic is caring for a client who has been experiencing mild to moderate vertigo due to benign paroxysmal vertigo for several weeks. Which of the following actions should the nurse recommend to help control the vertigo? (Select all that apply.) -Plan evenly spaced daily fluid intake. -Move head slowly when changing positions. -Avoid fruits high in potassium. -Avoid smoking. -Reduce exposure to bright lighting.

-Plan evenly spaced daily fluid intake. -Move head slowly when changing positions. -Reduce exposure to bright lighting. Remaining in a darkened, quiet environment can reduce vertigo, particularly when it is severe. Moving slowly when standing or changing positions can reduce vertigo. The client who has vertigo should be instructed to avoid foods containing high levels of sodium to reduce fluid retention, which can cause vertigo. Fluid intake should be planned so that it is evenly spaced throughout the day to prevent excess fluid accumulation in the semicircular canals. Smoking has no effect on vertigo.

The LPN opens several sterile 4 X 4's on the client's over-bed table. The LPN knows that the sterile dressings will be contaminated if she does which of the following? -Does not allow the dressings prolonged exposure to the air. -Keeps the sterile 4X 4's inside the border of the sterile packaging. -Positions the top of the table at or above waist level. -Pours sterile saline onto the opened sterile 4 X 4's on the table.

-Pours sterile saline onto the opened sterile 4 X 4's on the table. Capillary action and gravity lead to contamination of the sterile object because of contact between the non-sterile overbed table and the once-sterile fluid.

A nurse is checking the stoma of a client with a new colostomy and notes that the stoma appears pale. Which of the following actions should the nurse take? -Gently massage around the stoma. -Check the client's temperature. -Wash the area with warm water. -Prepare the client for surgery.

-Prepare the client for surgery. Checking the temperature will not improve circulation to the stoma and will waste valuable time. Washing the area with warm water will not improve circulation to the stoma and will waste valuable time. Massaging around the stoma will not improve circulation and can injure the tissue around the stoma. A pale stoma indicates that the circulation is compromised and immediate intervention is necessary. The nurse should prepare the client for surgery.

The LPN student is presenting information to the class about osteoarthritis. Which of he following would NOT be included as a risk factor for osteoarthritis? -Gender -Age -Weight -Race

-Race All of them except race are risk factor for osteoarthritis to include age, genetic predisposition, females more prone, obesity, mechanical factors like trauma or sports injuries and prior inflammatory disease.

The LPN hears a client calling for help. The LPN enters the room and finds an elderly client in bilateral wrist restraints with a cool, pale right hand with no palpable pulse. Which of the following would be the most appropriate for the LPN to take FIRST? -Reposition the client to reduce pressure. -Massage the client' wrist and hand -Leave to find the client's nurse -Remove the right restraint

-Remove the right restraint Removing the restraint provides the most immediate and effective way to help return circulation to the wirst and hand, the LPN can call for help and turn on the client's call light for further assistance and assessment.

The LPN is reviewing a client's morning laboratory findings. The nurse notes that the client's serum creatinine level is elevated. Which of the following systems does this diagnostic test show the function of? -Cardiovascular -Renal -Hepatic -Pulmonary

-Renal Elevated creatinine represents renal function.

A client is receiving a continuous gastric tube feeding at 100 mL per hour. The LPN checks for feeding residual and finds 90 mL in the client's stomach. Which of the following actions should the LPN take? -Discard the residual and stop the tube feeding. -Return the residual to the stomach and stop the tube feeding. -Discard the residual and continue the tube feeding. -Return the residual to the stomach and continue the tube feeding.

-Return the residual to the stomach and stop the tube feeding. Residuals less than 150 mL should be returned to the stomach to maintain electrolyte balance; the feeding should be stopped because the residual is over the 50% of the volume fed in 1 hour.

The LPN is talking with a client who has come to the clinic because of a rapid heartbeat. The client is having great difficulty listening to the nurse's questions and is unable to complete the clinic intake paperwork. The nurse believes that the client's symptoms may be related to what type of psychological response? -Mild anxiety -Severe Anxiety -Moderate anxiety -Panic anxiety

-Severe Anxiety Severe anxiety manifests itself with physical symptoms such as headaches, palpitations, and insomnia and with emotional symptoms such as confusion, dread, and horror. The client has very limited attention span and has great difficulty completing simple tasks.

The LPN is caring for a client who suddenly reports chest pain. The LPN knows that which of the following symptoms would be MOST characteristic of an acute myocardial infarction? -Severe substernal pain radiating down the left arm. -Sharp, well-localized unilateral chest pain. -Colic-like epigastric pain. -Sharp, burning chest pain moving from place to place.

-Severe substernal pain radiating down the left arm. Sever substernal pain radiating down the left arm, crushing sensation. Sharp burning pain moving place to lace = anxiety disorder, colic like epigastric pain = GI disorder, Sharp localized unilateral pain to chest=pneumothorax.

A postoperative client requests medication for flatulence (gas pains). Which medication from the PRN list should the nurse administer to this client? -Magnesium hydroxide -Acetaminophen -Ondansetron -Simethicone

-Simethicone Simethicone is an antiflatulent used in the relief of pain caused by excessive gas in the gastrointestinal tract. Ondansetron is used to treat postoperative nausea and vomiting. Acetaminophen is a nonopioid analgesic. Magnesium hydroxide is an antacid and laxative.

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is reinforcing instructions to the client regarding the program. Which instruction should the nurse include? -Try to exercise before mealtime -Exercise should be performed during peak times of insulin. -Administer insulin after exercising -Take a blood glucose test before exercising

-Take a blood glucose test before exercising A blood glucose test performed before exercising provides information to the client regarding the need to eat a snack first. Exercising during the peak times of insulin effect or before mealtime places the client at risk for hypoglycemia. Insulin should be administered as prescribed.

A client tells a student nurse, "Don't tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always yelling at me and threatening me." Which of the following actions should the nurse take? -Keep the client's communication confidential, but talk to the client daily, using therapeutic communication to convince him to admit to hiding the knife. -Keep the client's communication confidential, but watch the client and his roommate closely. -Report the incident, but do not inform the client of the intention to do so. -Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others.

-Tell the client that this must be reported to health care staff because it concerns the health and safety of the client and others. The information cannot be kept confidential. Daily therapeutic communication is not an appropriate action to correct the client's behavior. The information cannot be kept confidential. Observing the client and his roommate is not an appropriate action. This is a serious safety issue that must be reported to the staff. Using the principle of veracity, the student tells this client truthfully what must be done regarding the issue. The client should be aware that the information will be reported to the health care staff.

The LPN is helping an CNA provide a bed bath to a comatose client who is incontinent. The LPN should intervene if which of the following actions is noted? -The CNA positions the client on the left side, head elevated. -The CNA places an incontinence diaper under the client. -The CNA answers the phone while wearing soiled gloves. -The CNA log rolls the client to provide back care.

-The CNA answers the phone while wearing soiled gloves. Contaminated gloves should be removed before the phone is answered.

The LPN observes a CNA applying a client's antiembolism stockings. What is the appropriate routine for these stockings? -The CNA is applying the stockings after observing the color and temperature of the skin. -The CNA is applying the stockings at night as the patient is getting ready to go to sleep. -The CNA is applying the stockings just before assisting the patient out of bed in the morning. -The CNA is applying the stockings just after assisting the patient with ROM leg exercises.

-The CNA is applying the stockings just before assisting the patient out of bed in the morning. The correct and best time for application of antiembolism stockings is in the morning, before the client gets out of bed or after the legs have been elevated for an amount of time.

A client is transferred to an extended care facility following a cerebrovascular accident (CVA). The client has a right-sided paralysis and has been experiencing dysphagia. The LPN observes an aide preparing the client to eat lunch. Which of the following situations would require an intervention by the LPN? -The client's head and neck are positioned slightly forward. -The aide water down the pudding to help the client swallow. -The client is in bed in high fowler's position. -The aide puts the food in the back of the client's mouth on the unaffected side.

-The aide water down the pudding to help the client swallow. Clients usually manage foods better if they are soft or semi soft more difficulty with liquids

A client with a diagnosis of major depression becomes more anxious, reports sleeping poorly, and seems to display increased anger. The nurse should make which interpretation about the client's behavior? -The client is responding normally to hospitalization. -The client may need some time off the unit. -The client is at increased risk for suicide. -The client is dealing with pertinent issues

-The client is at increased risk for suicide. The behaviors identified in the question may be manifested by the client who is contemplating suicide. In clients who are depressed, anger may be self-directed in the form of suicide. Many of these symptoms are those of the depressed client; however, with this client, these behaviors have increased. Hospitalization may actually lessen these symptoms in the depressed client because a feeling of hope or relief may occur once treatment begins. Dealing with pertinent issues may be traumatic, but this is not the best interpretation of the behavior. Time off the unit for this client could put the client at risk for injury.

The LPN is caring for a client who has lost the ability to speak. What is the best interpretation of a grimace on the client's face? -The client is frustrated -The client is surprised -The client is disinterested -The client is in pain

-The client is in pain Facial expression can communicate a lot of information when the patient is unable to speak. A grimace indicates fear or pain. Compressed lips is frustration, widening of the eyes indicates surprise or enthusiasm. A stare indicates dislike or disinterest.

The client diagnosed with major depressive disorder who was admitted to the psychiatric unit for treatment and observation a week ago suddenly appears cheerful and motivated. The LPN should be aware of which of the following? -The client is probably sleeping well because of medication. -The client has made new friends and has a support group. -The client is responding to treatment and is no longer depressed. -The client may have finalized a suicide plan.

-The client may have finalized a suicide plan. The client may have finalized a suicide plan, as depressed clients improve, their risk for suicide is greater because they are able to mobilize more energy to plan and execute suicide.

The LPN is caring for a client diagnosed with bipolar disorder. Which of the following behaviors by the client indicates that a manic episode is subsiding? -The client sits and talks with other clients at mealtimes. -The client begins to write a book about his life. -The client initiates an effort to start a radio stations on the unit. -The client tells several jokes at a group meeting.

-The client sits and talks with other clients at mealtimes. Manic clients have difficulty socializing because of flight of ideas and intrusiveness, usually cannot sit to eat and will carry fluids and foods around.

A client suspected of having an abdominal tumor is scheduled for a computed tomography (CT) scan with dye injection. The nurse should tell the client which information about the test? -Fluids will be restricted after the test. -The test takes approximately 2 to 3 hours -The dye injected may cause a warm, flushing sensation. -The test may be painful

-The dye injected may cause a warm, flushing sensation. The CT scan causes no pain and takes about 15 to 60 minutes to perform. The dye may cause a warm flushing sensation when injected. Fluids are encouraged following the procedure. If an iodine dye is used, the client should be asked about allergies to seafood or iodine.

A nurse is reviewing the health record of a student who was newly admitted to a university and is living in a dormitory. The health record indicates the student requires follow-up immunizations. Which of the following organisms should the nurse plan to vaccinate the student against? -The nurse should not plan to administer a vaccine against Streptococcus pneumoniae because the immunization is not recommended for this population group. -The nurse should plan to administer a vaccine against Neisseria meningitidis because it is recommended that college students living in close proximity be immunized to against meningitis. -The nurse should not plan to administer a vaccine against Bartonella henselae because there is no vaccine available against this organism. -The nurse should not plan to administer a vaccine for Rickettsia rickettsii because there is no vaccine available against this organism.

-The nurse should plan to administer a vaccine against Neisseria meningitidis because it is recommended that college students living in close proximity be immunized to against meningitis. The nurse should not plan to administer a vaccine against Streptococcus pneumoniae because the immunization is not recommended for this population group. The nurse should plan to administer a vaccine against Neisseria meningitidis because it is recommended that college students living in close proximity be immunized to against meningitis. The nurse should not plan to administer a vaccine against Bartonella henselae because there is no vaccine available against this organism. The nurse should not plan to administer a vaccine for Rickettsia rickettsii because there is no vaccine available against this organism.

Which of the following actions by the LPN would demonstrate recognition of the most important method for controlling the spread of infection? -The nurse applies clean gloves to change bed lines. -The nurse washes hands prior to and following contact with every client. -The nurse applies sterile gloves during tracheostomy care. -The nurse wears sterile gloves to empty a client's Foley bag.

-The nurse washes hands prior to and following contact with every client. Handwashing is the most effective method for controlling the spread of infection.

The LPN is providing care for a client with chronic lung disease who is receiving oxygen through a nasal cannula. The LPN should expect which of the following to occur? -The oxygen flow rate will be set at 2L/min or less. -The client's oral intake will be restricted. -Arterial Blood gasses will be drawn every 2 hours. -The client will be on strict bed rest.

-The oxygen flow rate will be set at 2L/min or less. The respiratory drive with COPD clients can be suppressed by high levels of oxygen.

The nurse is caring for a client with bipolar disorder. Which of the following meals would be most appropriate for this client during a manic episode? -Turkey with gravy, mashed potatoes and peas -Spaghetti and meatballs with a salad. -Tomato soup, cheese slices, and an apple -Tuna sandwich cut in quarter, celery sticks, and orange slices.

-Tuna sandwich cut in quarter, celery sticks, and orange slices. Nutritionally balanced finger food meals are preferred when choosing foods for a client because they don't require sitting still and focusing.

A pregnant woman, who admits to intravenous drug use, had a negative human immunodeficiency virus (HIV) screening test just after missing her first menstrual period. Which assessment data would indicate the client needs to be retested for HIV? -Unusual fatigue and oral thrush -Shortness of breath and frequent urination -Hemoglobin of 11 g/dL and a rapid weight gain -Elevated blood pressure and ankle edema

-Unusual fatigue and oral thrush The client who is HIV-positive would have a suppressed immune system and would experience symptoms of fatigue and opportunistic infections such as oral thrush. The client with HIV would be anemic and anorexic. The client would have a decrease in blood pressure, and no ankle edema. Shortness of breath and frequent urination do not indicate a need to retest for HIV.

Newborn babies are given an injection on the day of birth to increase blood coagulation factors, which are present in deficient amounts in the neonates' bodies. Which of the following medications does this injection consist of? -Erythromycin -Ferrous sulfate -RhoGAM -Vitamin K

-Vitamin K The immature intestinal tract of the newborn does not contain the flora that produces the body's Vitamin K, therefore infants are injected with Vitamin K at birth to prevent potential bleeding caused by the deficiency.

The LPN is performing a surgical scrub prior to entering a neonatal intensive care unit. What step is MOST important for the nurse to perform prior to beginning the surgical scrub? -Put a surgical mask on -Clean under the fingernails -Wash hands with soap and water. -Put on sterile gloves.

-Wash hands with soap and water. Before proceeding with a surgical scrub, the nurse must first wash her hands with soap and water. Cleaning under the fingernails will occur with the surgical scrub.

The LPN is caring for a client who suddenly begins to vomit and the nurse's face is splashed with vomitus. What is the first step the nurse should take in this situation? -Call the nursing supervisor -Inform the infection control nurse. -Wash the face with liberal amounts of water -Wipe the vomitus off the face with a paper towel.

-Wash the face with liberal amounts of water In the event of an unexpected exposure to possible bloodborne pathogens, the nurse should minimize the exposure by washing the area thoroughly. Then the nurse would notify the appropriate personnel and fill out the necessary paperwork.

The LPN collects data about a client's fluid balance. Which of the following MOST accurately indicates to the LPN that the client has retained fluid during the previous 24 hours? -Intake of fluid exceed output by 200 mL -Weight gain of 4 lbs is noted. -Fluid intake is equal to fluid output -Edema is found in both ankle.

-Weight gain of 4 lbs is noted. Wight gain identifies fluid retention in a factual accurate method and is unlikely to represent a gain of actual body substance (muscle or fat) in a 24-hour time frame.

As a client nears death, the client's husband says, "I wish I could do something for her. " Which of the following responses by the LPN is MOST appropriate? -a. "It may be comforting to your wife if you talk to her calmly and clearly." -b. "Your wife does not know that you are here, but you can sit here with her." -c. "Unfortunately, there is little that you can do at this point" -d. "Why don't you take a break? It is just a matter of time now"

-a. "It may be comforting to your wife if you talk to her calmly and clearly."