LVN 4

A female client who had pelvic surgery 2 weeks ago is readmitted to the facility with a warm, tender, reddened area on her right calf. Which of the following contributing factors would the nurse recognize as most important? a) Recent pelvic surgery b) An active daily walking program c) History of increased aspirin use d) A history of diabetes

a) Recent pelvic surgery Reason: The client shows signs of deep vein thrombosis (DVT). The pelvic area is rich in blood supply, and thrombophlebitis of the deep veins is associated with pelvic surgery. Aspirin, an antiplatelet agent, and an active walking program help decrease the client's risk of DVT. In general, diabetes is a contributing factor associated with peripheral vascular disease

A nurse is planning care for a client with Ménière disease. Which nursing diagnosis takes highest priority? a) Risk for injury related to vertigo b) Imbalanced nutrition related to nausea and vomiting c) Acute pain related to Ménière disease d) Risk for deficient fluid volume related to vomiting

a) Risk for injury related to vertigo Reason: Vertigo, the hallmark finding in Ménière disease, is a severe rotational whirling sensation that typically causes the client to fall when attempting to stand or walk. Because client safety is paramount, the nursing diagnosis of Risk for injury related to vertigo takes priority. Ménière disease doesn't cause pain. Although nausea and vomiting can lead to inadequate nutrition and fluid loss, these problems aren't as important as client safety

The nurse is collecting data on a 47-year-old client who has come to the physician's office for his annual physical. The nurse should keep in mind that one of the first physical signs of aging is: a) failing eyesight, especially close vision. b) having more frequent aches and pains. c) accepting limitations while developing assets. d) increasing loss of muscle tone.

a) failing eyesight, especially close vision. Reason: Failing eyesight, especially close vision, is one of the first signs of aging in middle life (ages 46 to 64). More frequent aches and pains begin in the early late years (ages 65 to 79). Increasing loss of muscle tone occurs in later years (ages 80 and older). Accepting limitations while developing assets is an example of socialization development that occurs in adulthood (ages 31 to 45)

The nurse is preparing a client who has been newly diagnosed with asthma for discharge. As part of his discharge orders, the client is prescribed albuterol via nebulizer every 8 hours for 3 days, followed by one dose daily thereafter. Which instruction should the nurse include when teaching the client about nebulizer use? a) "If you feel short of breath you can use your nebulizer more frequently than prescribed." b) "You should take your pulse before and after treatment; if your pulse rate increases by more than 30 beats/minute you should notify your physician." c) "You might develop nervousness and palpitations during your treatment; this is normal and will subside." d) "You can be flexible with scheduling your albuterol treatments."

b) "You should take your pulse before and after treatment; if your pulse rate increases by more than 30 beats/minute you should notify your physician." Reason: The nurse should show the client how to check his pulse rate. The client should be instructed to check his pulse rate before and after using his nebulizer and to call the physician if his pulse rate increases by more than 30 beats/minute. The nurse should instruct the client to use his nebulizer exactly as prescribed. Using the nebulizer more often than prescribed can cause the drug to lose effectiveness, or to produce uncomfortable adverse effects. The client should also be instructed to notify his physician if his shortness of breath worsens, the drug becomes less effective, or he develops palpitations, nervousness, or a hypersensitivity reaction such as a rash.

A client is prescribed misoprostol (Cytotec) for treatment of a gastric ulcer. The nurse should be alert for which common dose-related adverse reaction? a) Nausea b) Diarrhea c) Bloating d) Vomiting

b) Diarrhea Reason: Misoprostol commonly causes diarrhea. This reaction is usually dose-related. Nausea and vomiting are adverse reactions that might be associated with misoprostol administration, but they're uncommon. Bloating isn't an adverse reaction to misoprostol.

The nurse is preparing to provide contraceptive counseling for a young client. What should the nurse plan to do first? a) Perform a complete physical assessment of the client. b) Explore her own personal beliefs and feelings about contraception. c) Help determine the most appropriate contraceptive method for the client. d) Obtain a thorough health history from the client.

b) Explore her own personal beliefs and feelings about contraception. Reason: The nurse must first explore her own personal beliefs and feelings about contraception to detect biases; if biases exist, the nurse must refer the client to another health care professional. Only after exploring personal beliefs and feelings does the nurse obtain a thorough health history, perform a complete physical assessment, and help determine the most appropriate contraceptive method.

A client with heart failure develops pink, frothy sputum; coarse crackles; and restlessness. Which action should the nurse take first? a) Calculate the client's fluid balance. b) Place the client in high Fowler position. c) Notify the physician. d) Check the client's blood pressure.

b) Place the client in high Fowler position. Reason: High Fowler position position can help reduce venous return to the heart and also decrease lung congestion. Checking the client's blood pressure is important but doesn't take top priority. Calculating the client's fluid balance wouldn't be an immediate priority in an emergency. The physician should be notified after the client has been repositioned and evaluated

The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's: a) ankle. b) foot. c) lower thigh. d) knee.

b) foot. Reason: An elastic bandage should be applied from the distal area to the proximal area. This method promotes venous return. In this case, the nurse should begin applying the bandage at the client's foot. Beginning at the ankle, lower thigh, or knee doesn't promote venous return

Which term describes a clinical judgment that an individual, family, or community is more vulnerable to develop a certain problem than others in the same or similar situation? a) Actual nursing diagnosis b) Syndrome nursing diagnosis c) Risk nursing diagnosis d) Health promotion nursing diagnosis

c) Risk nursing diagnosis Reason: Risk nursing diagnosis refers to the vulnerability of a client, family, or community to health problems. An actual nursing diagnosis describes a human response to a health problem being manifested. Syndrome nursing diagnosis describes a cluster of nursing diagnoses that are addressed together through similar interventions. A health promotion nursing diagnosis is a diagnostic statement describing the human response to levels of wellness in an individual, family, or community that have a potential for enhancement to a higher state.

The nurse is administering two drugs concomitantly to a client. Which interaction, recognized by the nurse, occurs when two drugs with the same qualitative effects produce a response when given together that is greater than the response either drug produces when given alone? a) Hyporeactivity b) Tolerance c) Synergism d) Antagonism

c) Synergism Reason: Synergism, or a synergistic effect, occurs when two drugs with the same qualitative effects produce a response when given together greater than either drug produces when given alone. Tolerance is a decreased response or decreased sensitivity of the receptor to a drug. Antagonism occurs when the combined response to two drugs given together is less than the response either drug produces when given alone. Hyporeactivity is a less-than-usual response to a normal drug dose

A client with type 1 diabetes who's in the second trimester of pregnancy is consuming a 2,400-calorie American Diabetes Association diet divided into three meals and several snacks. Her breakfast meal plan consists of these exchanges: 3 breads, 1 meat, 1 fruit, 1 milk, and 2 fats. Which menu would best comply with the meal plan? a) 2 bagels (½ bagel per exchange), 1 cup cooked grits, 3 eggs, 1 banana, 1 cup whole milk, 3 tsp margarine b) 3 breadsticks, 2 oz ham, 30 grapes (15 grapes per exchange), and 2 tsp margarine c) 4 breadsticks, 1 oz ham, 1 small apple, 2 bacon slices, and 1 cup low-fat yogurt d) 1 English muffin, ½ cup cooked grits, 1 egg, ½ banana, 1 cup skim milk, and 2 tsp margarine

d) 1 English muffin, ½ cup cooked grits, 1 egg, ½ banana, 1 cup skim milk, and 2 tsp margarine Reason: The first menu is best for the pregnant client with type 1 diabetes and includes the following exchanges: 3 breads (2 halves of the English muffin plus ½ cup cooked grits), 1 meat (1 egg), 1 fruit (½ banana), 1 milk (1 cup skim milk), and 2 fats (2 tsp margarine). The second menu exceeds the bread, meat, and fat exchanges. The third menu exceeds the bread exchanges. The fourth menu exceeds the meat and fruit exchanges.

A client is prescribed acetaminophen by mouth every 4 hours as needed for headache. Which factor in the client's medical history would cause the nurse to question this order? a) Bleeding disorder b) Allergy to salicylates c) Duodenal ulcer d) Cirrhosis

d) Cirrhosis Reason: Acetaminophen can cause liver failure, so the nurse should question its use in a client with a history of cirrhosis. An order for aspirin should be questioned in a client with a history of duodenal ulcer, salicylate allergy, or bleeding disorder

A newly hired nurse is reviewing a health care practitioner's orders. Which of the following would the nurse expect that must be included in a medication order? Select all that apply. a) Client's allergies b) Possible adverse reactions c) Drug class d) Client's full name e) Physician's signature

d) Client's full name e) Physician's signature Reason: The physician's signature must be included in a medication order. Other components of a medication order include the client's full name, drug name, dosage form, dose amount, administration route, time schedule, and the date and time of the order. The drug class and possible adverse reactions aren't components of a medication order. Client allergies should be recorded in the client's chart, not on the medication order

A nurse observes a medical student walk into a client's room and begin questioning her about her current health status. The client appears reluctant to respond. How should the nurse intervene? a) Stay with the client until the medical student finishes his questions. b) Encourage the client to cooperate with the medical student. c) Tell the client that the only way for the medical student to learn is for clients to cooperate with him. d) Explain to the client that she has the right to refuse to answer questions asked by the medical student.

d) Explain to the client that she has the right to refuse to answer questions asked by the medical student. Reason: The client has the right to confidentiality about her health information. She may refuse to share her information if she wishes. The nurse can stay with the client until the medical student finishes his questioning if the client agrees to answer questions. Encouraging the client to cooperate with the medical student violates the client's rights. Telling the client that the only way for the medical student to learn is for her to cooperate is inappropriate and also violates the client's rights.

A nurse is preparing to perform an abdominal assessment. Which sequence would the nurse follow to effectively perform an abdominal examination on a client? a) Inspection, auscultation, palpation, and percussion b) Inspection, percussion, palpation, and auscultation c) Inspection, palpation, percussion, and auscultation d) Inspection, auscultation, percussion, and palpation

d) Inspection, auscultation, percussion, and palpation Reason: The correct sequence for abdominal assessment is inspection, auscultation, percussion, and palpation because this sequence prevents altering bowel sounds with palpation before auscultation. The correct sequence for all other assessments is inspection, palpation, percussion, and auscultation.

A nurse works in a mental health facility that uses a therapeutic community (milieu) approach to client care. Which statement describes the nurse's role in this facility? a) Distinctly separate from the psychiatrist b) Supervisor more than counselor c) Primary caregiver d) Member of the milieu

d) Member of the milieu Reason: In a therapeutic community, everything focuses on the client's treatment. Staff and clients work together as a team or member of the milieu. The nurse wouldn't be a primary caregiver, but would work with the psychiatrist. The nurse's role could be that of supervisor as well as counselor.

Before clients can learn, they must believe that they need to learn the information. The nurse recognizes that this is an example of which learning principle? a) Initiative b) Maturation c) Motivation d) Relevance

d) Relevance Reason: Clients are more receptive and ready to learn if they believe that information being presented is real and relevant to them

Which statement is correct about the diagnosis of somatoform disorders? a) The somatic complaints are limited to one organ system. b) They're physical conditions with organic pathologic causes. c) The event preceding the physical illness occurred recently. d) They're disorders that occur in the absence of organic findings.

d) They're disorders that occur in the absence of organic findings. Reason: The essential feature of somatoform disorders is a physical or somatic complaint without any demonstrable organic findings to account for the complaint. There are no known physiological mechanisms to explain the findings. Somatic complaints aren't limited to one organ system. The diagnostic criteria for somatoform disorders state that the client has a history of many physical complaints beginning before age 30 that occur over several years