NCLEX Study Questions
The LPN/LVN assists the ostomy nurse to teach a client with a sigmoid colostomy about how to perform a colostomy irrigation. Which action should the LPN/LVN demonstrate during the teaching session? 1.Dilate the stoma gently with gloved finger. 2.Irrigate the colostomy using 30 cc of normal saline. 3.Continue irrigating until all stool is removed. 4.Returns should occur 5 to 10 min after instilling water.
1.Dilate the stoma gently with gloved finger.
A client with a history of migraine headaches is diagnosed with viral hepatitis. It is MOST important for the LPN/LVN to perform which of the following client teaching? 1."Do not take Tylenol for the headaches." 2."You may have a glass of wine with meals." 3."If your hands are kept clean, you may wear artificial nails." 4."Wash hands thoroughly before eating or drinking."
1."Do not take Tylenol for the headaches."
The LPN/LVN helps the lead nurse teach prenatal classes in the antepartum clinic. Which of the following statements, if made by a client to the LPN/LVN, indicates that further teaching is necessary? 1."I may feel hot flashes and chills." 2."I may experience constipation." 3."I may have leg cramps during the night." 4."I may feel irregular, painless contractions."
1."I may feel hot flashes and chills."
The LPN/LVN cares for an obese client diagnosed with autoimmune thrombocytopenic purpura. Because the client is immobile, it is MOST important for the LPN/LVN to give the nursing assistants which of the following instructions? 1."Use a turn sheet when repositioning the client." 2."Set up contact isolation precautions." 3."Help the client floss his teeth." 4."During transfer to a chair, do not allow weight bearing."
1."Use a turn sheet when repositioning the client."
The LPN/LVN cares for clients in the long-term care facility. The LPN/LVN identifies which clients are likely to develop a potassium imbalance? Select all that apply: 1.A client diagnosed with chronic kidney disease. 2.A client diagnosed with osteoarthritis. 3.A client experiencing vomiting and diarrhea. 4.A client receiving furosemide. 5.A client recovering from a stroke. 6.A client diagnosed with Parkinson's.
1.A client diagnosed with chronic kidney disease. 3.A client experiencing vomiting and diarrhea. 4.A client receiving furosemide.
After making rounds, the LPN/LVN needs to report status changes on several clients to the supervising nurse. The LPN/LVN should report which of the following changes FIRST? 1.A client who has developed an irregular heart rhythm. 2.A client whose serum high-density lipids is 170 mg/dL. 3.A client who has slight oozing of blood from a cardiac catheterization site. 4.A client who has inflammation at the insertion site of total parenteral nutrition (TPN) catheter.
1.A client who has developed an irregular heart rhythm.
The LPN/LVN cares for clients in the long-term care facility. After receiving report, which of the following clients should the LPN/LVN see FIRST? 1.A client with a hemoglobin of 6.9 g/dL. 2.A client with an oxygen saturation of 93% on 2 liters oxygen per nasal cannula. 3.A client requesting medication for nausea. 4.A client complaining of abdominal pain and requesting pain medication.
1.A client with a hemoglobin of 6.9 g/dL
A young adult with hemophilia bumps the knee and develops painful swelling of the knee. In providing care for the client, which action is the most appropriate for the LPN/LVN to take initially? 1.Apply ice to the injured knee and elevate the leg. 2.Prepare the client for blood administration. 3.Explain physical limitations to the client. 4.Administer analgesics for pain for 24 hours.
1.Apply ice to the injured knee and elevate the leg.
The LPN/LVN cares for clients in the pediatric clinic. The LPN/LVN understands that according to Erikson's stages of psychosocial development, trust and significant early attachments develop during which of the following years of life? 1.Birth to 18 months. 2.8 months to 3 years. 3.3 to 6 years. 4.6 to 12 years.
1.Birth to 18 months.
The LPN/LVN admits a middle-aged client with terminal lung cancer to the hospital. The spouse states the client did not want to come to the hospital and has no desire to "slow down." The LPN/LVN should give priority to which measure? 1.Encourage the client to participate in planning own care. 2.Set limits on the client's excessive activities. 3.Encourage the client to accept help from others. 4.Promote rest and relaxation for the client.
1.Encourage the client to participate in planning own care.
The LPN/LVN assists in the management of the home care of an elderly client who has had pernicious anemia for 10 years. Because of a common complication associated with the disease, it is MOST important that the LPN/LVN instruct the client about which of the following procedures? 1.Gastroscopy. 2.Liver biopsy. 3.Complete blood count. 4.Bone marrow transplant.
1.Gastroscopy.
A teenage boy is hospitalized for facial surgery. Based on his stage of development, the LPN/LVN anticipates that his greatest concern is likely to be which of the following? 1.How acceptable he is to his peers. 2.How attractive he is to females. 3.How much schoolwork he is missing. 4.What shows are on television.
1.How acceptable he is to his peers.
When assessing a client admitted with a severe headache and a body temperature of 103.7°F (39.8°C), the LPN/LVN notes that when the client's head is flexed, the client flexes the hips and knees. Which activity by the LPN/LVN is best? 1.Immediately notify the assigning nurse. 2.Continue with the nursing assessment. 3.Administer medication prescribed for the pain. 4.Place the client in high Fowler position and start oxygen at 2 L.
1.Immediately notify the assigning nurse.
Immediately following a liver biopsy, the LPN/LVN administers morphine sulfate 3 mg IM to the client. It is MOST important for the LPN/LVN to instruct the nursing assistants to perform the following? 1.Make sure client remains on the right side. 2.Keep client positioned on the left side. 3.Instruct client to remain prone for 4 hours. 4.Assist client into the supine position. View Explanation
1.Make sure client remains on the right side.
The nursing team consists of two RNs, two LPN/LVNs, and two patient care technicians. The LPN/LVN determines that delegation is appropriate if the LPN/LVN is assigned which of the following? 1.Perform a sterile dressing change. 2.Obtain vital signs. 3.Stock supplies of syringes and dressings. 4.Transfer a stable patient to x-ray.
1.Perform a sterile dressing change.
The client returns to a long-term medical inpatient unit after a gastroscopy is performed. The LPN/LVN instructs the nursing assistants to perform which of the following? 1.Provide client with a pitcher of ice water after the gag reflex returns. 2.Place the client in the Trendelenburg position for three hours 3.Report abdominal cramping and distention. 4.Measure the client's vital signs q 2 h.
1.Provide client with a pitcher of ice water after the gag reflex returns
The LPN/LVN cares for clients in the long-term care facility. When delegating care of clients to other staff members, the LPN/LVN should utilize which of the following techniques? Select all that apply: 1.The LPN/LVN maintains eye contact with the staff member. 2.The LPN/LVN asks staff members to report any problems. 3.The LPN/LVN states what, how, and when a task should be performed. 4.The LPN/LVN tells the nursing staff that feedback is not required after completing care. 5.The LPN/LVN tells the staff the reason the task is to be completed. 6.The LPN/LVN tells the staff to establish a timeline to complete the task.
1.The LPN/LVN maintains eye contact with the staff member. 3.The LPN/LVN states what, how, and when a task should be performed. 5.The LPN/LVN tells the staff the reason the task is to be completed.
The LPN/LVN makes a home visit to a client receiving chemotherapy for the treatment of cancer. The LPN/LVN instructs the client about ways to avoid injury due to bone marrow suppression. The LPN/LVN should intervene if which of the following is observed? 1.The client takes Alka-Seltzer for indigestion. 2.The client uses an electric razor to shave. 3.The client blows his nose gently. 4.After bumping the leg, the client applies ice for 30 minutes. View Explanation
1.The client takes Alka-Seltzer for indigestion.
The LPN/LVN who is assisting the school nurse is informed that a sixth grader in the school has been diagnosed with hepatitis A. It is MOST important for the LPN/LVN to reinforce instructions about which of the following measures to prevent hepatitis A? 1.Wash hands thoroughly after using the bathroom 2.Avoid contact with blood-contaminated items 3.Purchase protective masks for school 4.Withdraw child from school for 3 weeks
1.Wash hands thoroughly after using the bathroom
Ondansetron HCl (Zofran) 6 mg PO q 6 hr is ordered for a client. The LPN/LVN knows that which of the following times is the MOST appropriate to administer this medication? 1.1 hour after chemotherapy. 2.30 minutes before start of chemotherapy. 3.2 hours after chemotherapy. 4.When the client complains of nausea. View Explanation
2.30 minutes before start of chemotherapy.
The LPN/LVN cares for clients in the gynecological clinic. Which of the following clients should the nurse see FIRST? 1.A 60-year-old female complaining of dry vaginal wall and painful intercourse. 2.A 35-year-old female post-hysterosalpingogram who is experiencing tachycardia and a generalized rash. 3.A 30-year-old female requiring preparation for a cervical biopsy. 4.A 25-year-old female scheduled for a Pap smear.
2.A 35-year-old female post-hysterosalpingogram who is experiencing tachycardia and a generalized rash.
The home health LPN/LVN reinforced teachings to the parents of an adolescent client about prescribed antidepressants. The LPN/LVN determines further teaching is necessary if the client's mother makes which statement? 1."This medication will take a long time to become effective." 2."I am looking forward to my child getting better so he can stop taking the medication." 3."I will encourage my child to drink plenty of water." 4."I will administer the medication at night."
2."I am looking forward to my child getting better so he can stop taking the medication."
An 18-month-old girl is about to receive an immunization injection, and she begins to cry. Which of the following comments by the LPN/LVN is the MOST appropriate? 1."Don't cry. It will be better if you try to behave." 2."I know you are frightened. It will be over with soon." 3."A big girl like you shouldn't cry. You know it is not going to hurt." 4."Please stop crying. There is nothing to be afraid of."
2."I know you are frightened. It will be over with soon."
The LPN/LVN performs a home care visit on a mother who delivered a baby 3 days ago. The client expresses alarm when she hears that her baby has lost 8 oz. Which of the following responses by the LPN/LVN is MOST appropriate? 1."Perhaps you don't have enough milk for the baby and need to supplement his diet with formula." 2."That is a normal weight loss. Babies sometimes lose as much as 10% of the birth weight." 3."Babies usually lose some weight, but that's more than usual. He may need an intravenous infusion." 4."Most babies immediately lose their intrauterine water deposits and 20% of their birth weight."
2."That is a normal weight loss. Babies sometimes lose as much as 10% of the birth weight."
The adult client scheduled for a mammogram states, "My breasts are so large. I'm afraid they won't be able to do the test." Which response by the LPN/LVN is best? 1."Don't worry; they have done this procedure many times." 2."The size of your breasts will not affect the test." 3."I'll notify your health care provider so a biopsy can be scheduled instead." 4."Many people feel the same way you do." View Explanation
2."The size of your breasts will not affect the test."
The LPN/LVN cares for clients in the long-term care facility. After receiving report, which of the following clients should the LPN/LVN see FIRST? 1.A client diagnosed with type 2 diabetes has pale, cool skin and is complaining of a headache. 2.A client diagnosed with type 1 diabetes has a fruity breath smell and is drinking large quantities of water. 3.A client diagnosed with type 2 diabetes has a B/P of 120/50 mm Hg and is urinating frequently. 4.A client diagnosed with type 1 diabetes has a B/P of 90/60 mm Hg and skin is hot and dry to touch.
2.A client diagnosed with type 1 diabetes has a fruity breath smell and is drinking large quantities of water.
The LPN/LVN comes on a multi-vehicle accident on the freeway. Which accident victim should the LPN/LVN see first? 1.A client with a 2-inch-long scalp laceration. 2.A client with clear fluid draining from the right ear. 3.A client with a hematoma on the forehead. 4.A client whose pupils are equal and reactive to light.
2.A client with clear fluid draining from the right ear.
The LPN/LVN receives patient assignments from the charge nurse and prepares to make rounds on the assigned patients. Which of the following patients should the LPN/LVN see FIRST? 1.A patient with normal saline infusing IV at 125 ml per hour and complains of slight swelling at the IV insertion site. 2.A patient 3 days post right-knee replacement complaining of right calf pain with movement. 3.A patient drinking contrast for an abdominal CT scan and complains of nausea. 4.A patient with a respiratory rate of 24 and an oxygen saturation of 94% on room air.
2.A patient 3 days post right-knee replacement complaining of right calf pain with movement.
Because a client is diagnosed with end stage liver disease, the LPN/LVN knows which action should be included in the nursing care plan? 1.Administer aspirin for pain. 2.Administer fat-soluble vitamin supplements. 3.Monitor serum amylase levels. 4.Monitor serum calcium levels.
2.Administer fat-soluble vitamin supplements.
The LPN/LVN performs a home care visit to a middle-aged female client diagnosed with iron-deficiency anemia. The client states that even though she is taking her "iron pill" daily, she is feeling more and more fatigued. Which of the following actions should the LPN/LVN take FIRST? 1.Instruct the client to balance rest and activity. 2.Ask about characteristics of menses. 3.Contact the physician. 4.Instruct the client about eating foods high in iron.
2.Ask about characteristics of menses.
The LPN/LVN cares for a middle-aged adult diagnosed with Buerger disease. The client's spouse and adolescent children begin working to meet the family's financial needs. During a home visit, it is most important for the LPN/LVN to report which finding to the supervising nurse? 1.The client spends most of the day on the internet. 2.At times, the client is verbally abusive to his spouse. 3.The client watches television most of the day. 4.The client is withdrawn and sleeps most of the day.
2.At times, the client is verbally abusive to his spouse.
The LPN/LVN notices that an intravenous infusion not on a pump is not running. Which action should the LPN/LVN initiate first? 1.Reposition the client's arm. 2.Check the site. 3.Raise the IV solution. 4.Flush the tubing.
2.Check the site.
The LPN/LVN assists in the care of a client who is in active labor. As labor progresses, the client becomes irritable and complains of feeling increasingly uncomfortable. She is 8 cm dilated. Which of the following actions should the LPN/LVN take FIRST? 1.Contact the physician. 2.Coach the patient in proper breathing and relaxation techniques. 3.Administer a narcotic analgesic. 4.Remove the fetal monitor to allow the client to move around.
2.Coach the patient in proper breathing and relaxation techniques.
In order to prevent parent-child disturbances, it is MOST important for the LPN/LVN to take which of the following actions? 1.Report potential abuse to the appropriate authorities. 2.Discuss with the parents any problems or fears about child rearing that they may have. 3.Tell the parents that if their attitudes don't change, action will have to be taken by the medical staff. 4.Suggest to the parents that they have the child stay with a relative until they feel confident in their roles.
2.Discuss with the parents any problems or fears about child rearing that they may have
Which of the following nursing actions is MOST important for the LPN/LVN to take to provide effective pain relief for a client? 1.Teach the client about pain. 2.Establish a trusting relationship with the client. 3.Determine how various relaxation techniques affect the pain. 4.Administer pharmacological agents.
2.Establish a trusting relationship with the client.
Because blood has been oozing continuously from the vagina of a postoperative client after a vaginal hysterectomy, 2 units of whole blood are ordered. As the LPN/LVN collects the pre-transfusion vital signs, the client states she does not want the blood transfusions because of religious beliefs. Which of the following responses by the LPN/LVN is BEST? 1.Instruct the client to discuss the matter with the surgeon. 2.Immediately report the information to supervising nurse. 3.Assure the client that the blood has been carefully screened. 4.Explain the importance of replacing the blood lost after surgery.
2.Immediately report the information to supervising nurse.
Because of specific physiological changes in clients with cirrhosis, the home care LPN/LVN teaches the family that the client should include the following nutrients in the daily diet? 1.Increased calories and decreased vitamins. 2.Increased protein and increased carbohydrates. 3.Increased calcium and decreased fat. 4.Increased iron and decreased salt. 3.Increased calcium and decreased fat. 4.Increased iron and decreased salt.
2.Increased protein and increased carbohydrates
The LPN/LVN selects which nursing goal as most realistic and appropriate when implementing care for a client with Parkinson's disease? 1.Return the client to usual activities of daily living. 2.Maintain optimal function within the client's limitations. 3.Prepare the client for a peaceful and dignified death. 4.Arrest progression of the disease process.
2.Maintain optimal function within the client's limitations.
To effectively control the most common complication associated with long term total parenteral nutrition (TPN), the LPN/LVN is most likely to instruct the nursing assistive personnel to perform which action? 1.Report signs/symptoms of respiratory distress. 2.Measure finger stick blood glucose q 4 h. 3.Report venipuncture site redness and edema. 4.Report weight gain >3 lb/daily.
2.Measure finger stick blood glucose q 4 h.
An LPN/LVN answers the call light of a client diagnosed with Addison's disease. The client suddenly begins vomiting and reports feeling light-headed. The MOST appropriate nursing action by the LPN/LVN includes which of the following? 1.Lower the head of the bed and cover the client with blankets. 2.Measure the client's blood pressure and perform finger stick for blood sugar. 3.Administer prn antiemetic medication. 4.Assess components of the vomitus.
2.Measure the client's blood pressure and perform finger stick for blood sugar.
After a gastrectomy for stomach cancer, a nursing assistive person tells the LPN/LVN the nasogastric tube is "plugged up" and the client reports severe nausea. It is most important for the LPN/LVN to take which action? 1.Irrigate the nasogastric tube immediately. 2.Notify the supervising nurse. 3.Advance the tube if coughing partially expels it. 4.Place client in supine position.
2.Notify the supervising nurse.
The LPN/LVN identifies which nursing goal as the highest priority when caring for a client with a history of seizures? 1.Prevent the occurrence of fractures. 2.Protect the head and neck from injury. 3.Provide adequate emotional support. 4.Protect from physical exposure or social bias.
2.Protect the head and neck from injury.
The LPN/LVN in the outpatient clinic cares for a client who is diagnosed with hepatitis A. The client relates to the nurse that she is the single parent of five children under the age of 9 and that she is unable to care for the children due to the illness. The client decides that her children should stay with their father until she recovers. It is MOST important for the LPN/LVN to take which of the following actions? 1.Determine where the client contracted hepatitis A. 2.Remind the client to send the children's favorite toys with them. 3.Inform the client that her children have already been exposed and should remain with her. 4.Instruct the client to dispose of sanitary napkins by placing them in separate plastic bag.
2.Remind the client to send the children's favorite toys with them.
While monitoring a client receiving an intravenous infusion of doxorubicin (Adriamycin), the LPN/LVN notes that the infusion rate has decreased, and the client's hand is slightly swollen. Which of the following actions should the LPN/LVN take FIRST? 1.Increase the infusion rate. 2.Stop the infusion. 3.Apply warm compress to the hand and continue the infusion. 4.Apply cold compress to the hand and continue the infusion.
2.Stop the infusion.
The LPN/LVN cares for a client complaining of sudden onset of severe right flank pain. The client is diagnosed with urinary calculi. Which of the following nursing actions has the HIGHEST priority? 1.Ensure the client remains NPO. 2.Strain the urine through several layers of gauze. 3.Assess the client's grip strength and pupil reactivity. 4.Obtain a clean-catch urine specimen.
2.Strain the urine through several layers of gauze.
When assessing the abdomen, the LPN/LVN should place the client in which of the following positions? 1.Supine. 2.Supine with knees flexed. 3.Side lateral. 4.Sims'.
2.Supine with knees flexed.
The LPN/LVN assists in the management of the health care of an older adult client suspected of having syndrome of inappropriate antidiuretic hormone (SIADH). The LPN/LVN is MOST concerned if which of the following is observed? 1.The client's serum sodium level is 137 mEq/L. 2.The client is drinking water. 3.The client is oriented to person, place, and time. 4.The client is lying in bed with the rails up.
2.The client is drinking water.
A client with severe diverticulitis is admitted to the hospital for bowel surgery, and a colostomy is performed. Which observation of the stoma would cause the LPN/LVN to reassure the client that the stoma is normal? 1.The stoma is bluish and dry. 2.The stoma is beefy-red. 3.The stoma is gray and small. 4.The stoma is dark and pulsating.
2.The stoma is beefy-red.
The LPN/LVN cares for clients in the long-term care facility. Which of the following clients should the LPN/LVN see FIRST? 1.A client diagnosed with type 2 diabetes has pale, cool skin and is complaining of a headache. 2.A client diagnosed with a CVA has frequent watery diarrhea. 3.A client diagnosed with asthma has labored breathing. 4.A client diagnosed with chronic renal failure has a B/P of 150/90 mm Hg.
3.A client diagnosed with asthma has labored breathing.
On the day of discharge, a client newly diagnosed with diabetes says, "Tell me again, what should I do if I develop a fever?" Which of the following is the BEST response by the LPN/LVN? 1."Increase your caloric intake and decrease your insulin dosage." 2."Discontinue taking insulin until after your febrile state has passed." 3."Continue to monitor blood sugar and take insulin as prescribed." 4."See your physician to have your insulin dosage adjusted."
3."Continue to monitor blood sugar and take insulin as prescribed."
The LPN/LVN leads a smoking cessation class. Which of the following instructions should the LPN/LVN give FIRST? 1."Remove ashtrays and lighters from view." 2."Go to places that tempt you to smoke to test your resolve." 3."Make a list of all of the reasons to quit smoking." 4."Drink at least 8 glasses of water per day."
3."Make a list of all of the reasons to quit smoking."
After the LPN/LVN completes the hospital health history form for a client suspected of having cirrhosis, the LPN/LVN posts which sign above the head of the client's bed? 1."Seizure precautions." 2."Do not raise head of bed." 3."No IM injections." 4."No blood pressures in left arm."
3."No IM injections."
The LPN/LVN receives a phone call from a young adult diagnosed with type 1 diabetes treated with humulin insulin. Because the client experienced decreased sexual abilities, he began taking an herbal supplement that he learned about when watching television. Which of the following responses by the LPN/LVN is MOST appropriate? 1."It is a good idea for you to see a physician about your sexual problems." 2."Is the medication helping you with the problem?" 3."Stop taking the medication until you can consult with your physician." 4."Did your blood sugar change after you started taking the herb?"
3."Stop taking the medication until you can consult with your physician."
The LPN/LVN on the medical/surgical unit has just received report. Which of the following clients should the LPN/LVN see FIRST? 1.A 29-year-old female undergoing peritoneal dialysis. The outflow appears bloody. 2.A 35-year-old male diagnosed with acute postinfectious glomerulonephritis. The client's BP is 150/90. 3.A 45-year-old female diagnosed with P. carinii pneumonia. The client complains of a persistent dry cough. 4.A 56-year-old male diagnosed with angina. The client is scheduled for discharge today.
3.A 45-year-old female diagnosed with P. carinii pneumonia. The client complains of a persistent dry cough.
The LPN/LVN cares for clients on the medical/surgical floor. The LPN/LVN determines assignments are appropriate if which of the following clients is assigned to the LPN/LVN? 1.A client returns after an appendectomy complicated by a pneumothorax during surgery. 2.A client with increased intracranial pressure who responds to painful stimuli. 3.A client diagnosed with cellulitis receiving antibiotics. 4.A client with a mandibular fracture immobilized by wiring the jaw prepares for discharge.
3.A client diagnosed with cellulitis receiving antibiotics.
An LPN/LVN assists in the outpatient clinic with the care of clients diagnosed with gastrointestinal (GI) alterations. The LPN/LVN identifies that which of the following client diagnoses has the GREATEST risk of impairing the client's health status? 1.A client diagnosed with multiple diverticula of the colon. 2.A client diagnosed with dental caries. 3.A client diagnosed with gastroesophageal reflux disease (GERD). 4.A client diagnosed with a hiatal hernia.
3.A client diagnosed with gastroesophageal reflux disease (GERD).
The LPN/LVN cares for clients in the outpatient clinic. Several clients exhibit signs/symptoms that may indicate early stage cancer. Although all of the clients are instructed to make appointments with their personal health care providers, the LPN/LVN STRONGLY encourages which of the following clients to make an IMMEDIATE follow-up appointment? 1.A client who complains of heavy menstrual periods. 2.A client who tests positive for occult blood in stool. 3.A client who develops spoon-shaped nails. 4.A client who has an increased white blood cell count.
3.A client who develops spoon-shaped nails.
The LPN/LVN on the medical surgical unit has just received report. Which of the following clients should the LPN/LVN see FIRST? 1.A client one day post-op after an appendectomy. 2.A client who had a detached retina surgically repaired 4 hours ago. 3.A client with an esophagogastric tube inserted. 4.A client 2 days post-op after a laminectomy with spinal fusion.
3.A client with an esophagogastric tube inserted.
The nursing team consists of two RNs, one LPN/LVN, and two nursing assistants. The LPN/LVN should consider the assignment appropriate if the RN assigns which of the following to the LPN/LVN? 1.Obtain vital signs for a patient immediately after ECT. 2.Assist a patient with bathing and feeding. 3.Administer a tube feeding for a patient with dysphagia. 4.Discharge a patient diagnosed with multiple sclerosis.
3.Administer a tube feeding for a patient with dysphagia.
The LPN/LVN cares for a client diagnosed with polycythemia vera. It is MOST important for the LPN/LVN to instruct the nursing assistants to perform which of the following? 1.Massage the lower limbs vigorously during the morning bath. 2.Assist the client with long, early morning walks. 3.Apply antipruritic lotion after completing the client's bath. 4.Measure vital signs q 4 hours.
3.Apply antipruritic lotion after completing the client's bath.
The LPN/LVN cares for clients in the outpatient clinic. A client with a freshly placed cardiac pacemaker becomes angry when he learns that he must discontinue playing football with his sons. It is MOST important for the LPN/LVN to take which of the following actions? 1.Instruct the client to report bilateral lower-limb edema. 2.Assess for elevated blood pressure. 3.Assist the client to identify interests in alternative activities. 4.Warn client of the consequences of failure to adhere to the guidelines.
3.Assist the client to identify interests in alternative activities.
The LPN/LVN provides care for a client 24 hours post appendectomy. The client has severe abdominal pain, a temperature of 101°F (38.3°C), and a rigid abdomen. Which action does the LPN/LVN take first? 1.Assists the client with ambulation down the hallway. 2.Asks the client's level of pain. 3.Auscultates the client's bowel sounds. 4.Observes the wound for odor and drainage.
3.Auscultates the client's bowel sounds.
The LPN/LVN is assigned to care for a client requiring a dressing change. The LPN/LVN tells the supervising nurse that the LPN/LVN observed a similar dressing change while in nursing school but has never performed the procedure. The supervising nurse should take which of the following actions? 1.Ask the LPN/LVN to review the hospital's procedure manual regarding dressing changes. 2.Review the steps of the dressing change with LPN/LVN. 3.Complete the dressing change this time and ask the LPN/LVN to observe. 4.Assign a more experienced LPN/LVN to the client.
3.Complete the dressing change this time and ask the LPN/LVN to observe.
The home health LPN/LVN arrives at the home of a post-myocardial infarction client. The LPN/LVN notes that the client's right leg is swollen and the client is crying because she thinks a swollen leg indicates her heart is failing. Which of the following actions should the LPN/LVN take FIRST? 1.Ensure that the client is knowledgeable about the prescribed medication. 2.Assess for signs and symptoms of depression. 3.Contact the physician. 4.Instruct the client to elevate the leg.
3.Contact the physician.
When witnessing the client's signing of an informed consent form, it is MOST important for the LPN/LVN to make which of the following assessments? 1.Does the client understand the procedure?2.Does the client have any questions? 3.Does the client give consent voluntarily? 4.Is the client able to write his name?
3.Does the client give consent voluntarily?
A client diagnosed with a duodenal ulcer has surgical repair of the perforated site. The client has a nasogastric tube (NG), an IV of 1,000 cc D5 1/2 Ringer's lactate at 80 mL/hr, and a Penrose drain inserted in the wound. Because the client finds the patent NG tube very uncomfortable, she asks the LPN/LVN to remove the tube "right now." Which of the following actions by the LPN/LVN is MOST appropriate? 1.Refuse to remove the tube. 2.Assess the contents of the drainage. 3.Explain why tube is necessary. 4.Inform client that physician will not permit removal of the tube.
3.Explain why tube is necessary.
Family members are having difficulty communicating with a client with confusion due to AIDS dementia complex. It is MOST important for the LPN/LVN to take which of the following actions? 1.Ask the client to identify the day and date. 2.Assist the client to answer questions asked by the family. 3.Give the client simple directions. 4.Explain the day's schedule during breakfast.
3.Give the client simple directions.
A client experiences numbness and decreased sensation in both lower extremities during the course of treatment with vinblastine (Velban). The LPN/LVN should include which of the following nursing actions when caring for the client? 1.Soak both legs in hot water qid. 2.Increase walking to three times a week for 30 minutes. 3.Instruct client to ambulate carefully with broad-based gait. 4.Elevate the client's legs while sitting.
3.Instruct client to ambulate carefully with broad-based gait.
The home care LPN/LVN visits a client after discharge from a rehabilitation center. The client is diagnosed with head injury and is depressed because he has difficulty going out. The client cannot tolerate environmental stimuli, such as the noise in grocery stores and malls and at school activities. Which of the following interventions by the LPN/LVN is BEST? 1.Suggest the client remain in his home until his noise tolerance improves. 2.Contact the health care provider for a prescription for an antidepressant. 3.Instruct the client to wear headphones with music playing when he goes out. 4.Recommend that the client seek psychotherapy.
3.Instruct the client to wear headphones with music playing when he goes out.
A client is admitted to the hospital with symptoms of myasthenia gravis. When caring for this client, the LPN/LVN should give first priority to which nursing goal? 1.Provide meticulous personal hygiene. 2.Maintain balance between activity and rest. 3.Maintain respiratory function. 4.Promote adequate hydration.
3.Maintain respiratory function.
The LPN/LVN cares for clients in the outpatient clinic. If the LPN/LVN provides care for a young adult, which primary developmental task is expected? 1.Separating from parents. 2.Seeking promotion to a high-level position. 3.Making a commitment to a lifetime mate. 4.Settling down and enjoying life.
3.Making a commitment to a lifetime mate.
The LPN/LVN assists in the teaching of a client recently diagnosed with type 1 diabetes about proper meal planning. Which of the following actions should the LPN/LVN have taken FIRST? 1.Instruct the client about the importance of eating regular meals. 2.Inform the client that 50 to 60% of calories should come from carbohydrates. 3.Obtain a diet history that includes the client's favorite foods and usual meals. 4.Teach the client how to use the Exchange List for Meal Planning.
3.Obtain a diet history that includes the client's favorite foods and usual meals.
The LPN/LVN cares for a client diagnosed with cirrhosis. After reviewing the record, what lab value should the LPN/LVN report to the supervising nurse? 1.Serum albumin 4.0 g/dL. 2.Serum aspartate aminotransferase (AST, SGOT) 38 units. 3.Serum alanine aminotransaminase (ALT, SGPT) 600 units. 4.Serum lactate dehydrogenase (LDH) 150 units.
3.Serum alanine aminotransaminase (ALT, SGPT) 600 units.
A client diagnosed with the syndrome of inappropriate antidiuretic hormone (SIADH) exhibits signs and symptoms commonly associated with the disease. Which of the following assessments should the LPN/LVN focus on FIRST? 1.Amount of weight the client gained. 2.An increase in the client's blood pressure. 3.Status of the client's nervous system. 4.The client complains of abdominal cramping.
3.Status of the client's nervous system.
The LPN/LVN makes a monthly assessment of a 77-year-old client in the long-term care facility. It is MOST important for the LPN/LVN to report which of the following assessments to the health care provider? 1.The client has lost 6 pounds in 4 weeks. 2.The client's dentures do not fit properly. 3.The client complains of a hard, painless ulcer between the tongue and the floor of the mouth. 4.The client appears to have difficulty hearing when the TV is turned on.
3.The client complains of a hard, painless ulcer between the tongue and the floor of the mouth.
By her fifth month of pregnancy, a 32-year-old prenatal multipara of average height and weight has gained 14 lb. The LPN/LVN recognizes that which of the following advice is needed? 1.The client has gained too much weight and her diet should be reevaluated. 2.The client has not gained enough weight and her diet should be reevaluated. 3.The client's weight gain is appropriate and she should continue on her present diet. 4.Because difficulties may occur, more visits to the physician are indicated.
3.The client's weight gain is appropriate and she should continue on her present diet.
The LPN/LVN observes a student practical nurse palpate uterine contractions. The LPN/LVN determines that the student is performing the technique correctly if which of the following is observed? 1.The student nurse places the palm of one hand on the fundus and moves the other hand in a circle. 2.The student places the heels of both hands on the lower abdomen and presses lightly. 3.The student nurse places the fingertips on the fundus and presses gently. 4.The student nurse places the palms of the hands on either side of the abdomen and presses firmly.
3.The student nurse places the fingertips on the fundus and presses gently.
The LPN/LVN initiates the discharge plan developed by the assigned nurse for the family of a client diagnosed with hepatic encephalopathy. Further teaching is necessary if the family makes which of the following statements to the LPN/LVN? 1.ʺWe should contact the health care provider if our parent is restless at night.ʺ 2.ʺLactulose will cause our parent to have 2 to 3 stools per day.ʺ 3.ʺOur parent should eat meat at every meal.ʺ 4.ʺLactulose may cause bloating and cramps.ʺ
3.ʺOur parent should eat meat at every meal.ʺ
The community health LPN/LVN plans visits for the day. Which of the following clients should the LPN/LVN see FIRST? 1.A client diagnosed with type 2 diabetes who is complaining of GI upset after taking chlorpropamide (Diabinese). 2.A client complaining of vomiting after chemotherapy. 3.A client with a tonometer reading of 21 mm Hg. 4.A client with a laryngectomy who is complaining of a greenish-yellow discharge.
4.A client with a laryngectomy who is complaining of a greenish-yellow discharge.
The supervising nurse discusses substance abuse among the nursing staff. Which of the following behaviors, if demonstrated by a staff member, should cause the LPN/LVN to alert the supervising nurse about a potential problem with substance abuse? 1.A staff member changes hair color frequently. 2.A staff member appears quiet in group meetings. 3.A staff member frequently arrives early for work. 4.A staff member does not allow another nurse to sign that narcotics are wasted.
4.A staff member does not allow another nurse to sign that narcotics are wasted.
The LPN discusses radioactive implant treatment with the client and her family. The LPN should provide which of the following instructions? 1. visits will be d/c until after the treatment is completed 2. treatment will be temporarily d/c to permit family visits 3. family visits are encouraged during treatment 4. visits must be limited and brief during treatment
4. visits must be limited and brief during treatment
An LPN/LVN implements the nursing care plan designed for a client diagnosed with angina pectoris. It is MOST important for the LPN/LVN to include which of the following instructions? 1."It is safe to take brisk, short walks during the winter months." 2."If you continue to have chest pain after taking 3 nitroglycerin tablets, notify your physician." 3."Beta-adrenergic blocking drugs such as propranolol (Inderal) cause dilation of cardiac blood vessels." 4."It is best for you to avoid ingesting large, heavy meals."
4."It is best for you to avoid ingesting large, heavy meals."
An LPN/LVN cares for residents in an assisted living facility. The LPN/LVN discovers an unconscious client lying on the floor beside the bed with a small, open lesion on the right side of the head. After caring for the client, the LPN/LVN prepares to write an incident report. Which entry is most appropriate for the incident report? 1."The client apparently fell out of bed." 2."Notified supervisor of the accidental head injury." 3."Apparently struck right side of head during fall." 4."Nonresponsive client found lying on floor beside bed."
4."Nonresponsive client found lying on floor beside bed."
The LPN/LVN cares for clients in the long-term care facility. After receiving report, which of the following clients should the LPN/LVN see FIRST? 1.A client with right-sided weakness requires assistance with A.M. care. 2.A client requires administration of digoxin (Lanoxin) and furosemide (Lasix). 3.The daughter of a client is upset because her father is diagnosed with terminal cancer. 4.A client is suddenly confused and sees spiders on the wall.
4.A client is suddenly confused and sees spiders on the wall.
The LPN/LVN cares for clients in the long-term care facility. After receiving report, which of the following clients should the LPN/LVN see FIRST? 1.A client due to receive blood pressure medicine. 2.A client due to receive a metered dose inhaler (MDI). 3.A client whose family member is threatening to sue the institution if the LPN/LVN doesn't talk to them immediately. 4.A client who has been verbally abusive to staff and is becoming increasingly more agitated.
4.A client who has been verbally abusive to staff and is becoming increasingly more agitated.
The LPN/LVN cares for clients in the long-term care facility. The nursing assistant reports that four clients are complaining of pain. Which of the following clients should the LPN/LVN see FIRST? 1.A client with a history of a herniated lumbar disc complaining of severe pain radiating down the left leg. 2.A client with a history of migraine headaches complaining of a headache with light sensitivity. 3.A client with a history of kidney stones is tearful and complaining of severe right flank pain. 4.A client with a history of coronary artery disease (CAD) complaining of midepigastric pain radiating to the neck.
4.A client with a history of coronary artery disease (CAD) complaining of midepigastric pain radiating to the neck.
The LPN/LVN cares for clients on the night shift at the long-term care facility. After receiving report, the LPN/LVN should delegate which of the following clients to a nursing assistant with 20 years of experience? 1.Assess the breathing pattern of a client who experienced an acute asthma attack 12 hours ago. 2.Monitor a client who is expectorating rust-colored sputum. 3.Administer codeine to a terminal client. 4.Bathe a patient before the patient is transported for a scheduled 9 A.M. surgery.
4.Bathe a patient before the patient is transported for a scheduled 9 A.M. surgery.
The LPN/LVN notes that the serum sodium level of a client diagnosed with heart failure (HF) is decreased. Which of the following activities should the LPN/LVN perform NEXT? 1.Notify the health care provider. 2.Assess the client's lung sounds and respiratory rate. 3.Assess for peripheral edema. 4.Compare current weight to the weight of the day before.
4.Compare current weight to the weight of the day before.
After administering pain medication to a client, which of the following actions is MOST appropriate for the LPN/LVN to take? 1.Do not disturb the client until the pain medication is due again. 2.Keep the environment cool and quiet for the rest of the day. 3.Provide diversional activities at short intervals. 4.Evaluate whether the medication is effective.
4.Evaluate whether the medication is effective.
Because of damage to the liver related to hepatitis C, a client is placed on the waiting list for an organ transplant. The client reports to the LPN/LVN the greatest challenge is dealing with the fatigue and the boredom. Which of the following interventions by the LPN/LVN is BEST? 1.Help the client recognize the physical limitations. 2.Encourage the client to be patient, because he may have to wait for a long time. 3.Determine if liver damage is progressing. 4.Help client identify valued activities in which to engage.
4.Help client identify valued activities in which to engage.
The LPN/LVN cares for a client diagnosed with end-stage liver disease. The client has an advanced directive stating that he does not want any blood transfusions. Because the client has severe rectal bleeding, the client's spouse becomes distraught and demands that the client receive blood transfusions. Which of the following actions should the LPN/LVN take NEXT? 1.Notify another family member about the problem. 2.Reassure the spouse that the client will be kept as clean as possible. 3.Inform the spouse that the advanced directive must be honored. 4.Notify the health care provider about the problem.
4.Notify the health care provider about the problem.
A client is admitted to the hospital with a white blood cell count of 1,500/mm 3. When caring for the client, the LPN/LVN should consider which of the following nursing diagnoses as the highest priority? 1.Ineffectual individual coping. 2.Fatigue. 3.Self-care deficit. 4.Risk for infection.
4.Risk for infection.
A young mother delivers a healthy 7-lb, 12-oz boy. While the LPN/LVN assists with perineal care, the client expresses concern about the two "soft spots" found on her baby's head. The LPN/LVN's response is based on which of the following? 1.Both of the baby's fontanels should close within the first month. 2.Both of the baby's fontanels should close within 6 months. 3.The baby's posterior fontanel should close after 1 year. 4.The baby's anterior fontanel should close after about a year and a half.
4.The baby's anterior fontanel should close after about a year and a half.
A nursing assistant caring for clients in the long-term care facility collapses minutes after putting on latex gloves. The assistant is successfully resuscitated. After reviewing the medical histories of the staff in the long-term care facility, the LPN/LVN determines which of the following staff members can safely use latex products? 1.The staff member with a history of allergies to pollen and grass. 2.The staff member with a history of allergies to banana and kiwi. 3.The staff member with a history of multiple surgeries. 4.The staff member with a history of GI upset.
4.The staff member with a history of GI upset.
The LPN/LVN assists the school nurse to care for students in the local high school. A student tells the LPN/LVN that the student's mother has been diagnosed with terminal cancer. Which of the following behaviors, if displayed by the student, should cause the LPN/LVN to report to the school nurse immediately? 1.The student is sad and cries frequently. 2.The student has lost 10 pounds and appears very sleepy. 3.The student is frequently absent and has declining grades. 4.The student appears happy and gives valued items to close friends.
4.The student appears happy and gives valued items to close friends.
The LPN/LVN participates in the preoperative instruction of a client scheduled for a colostomy. The LPN/LVN instructs the client that 24 hours after surgery the colostomy drainage will MOST likely look like which of the following? 1.There will be a large amount of bloody output. 2.There will be a large amount of liquid stool. 3.There will be formed stool with water. 4.There will be a scant amount of bright bloody drainage.
4.There will be a scant amount of bright bloody drainage.
The home care LPN/LVN visits a client undergoing external radiation for treatment of lung cancer. It is MOST important for the LPN/LVN to instruct the client about which of the following? 1.Use a washcloth to gently cleanse the irradiated area. 2.Apply cream to the irradiated area daily. 3.Apply sunscreen to the irradiated area if exposed to the sun. 4.Use a patting motion to dry the irradiated area.
4.Use a patting motion to dry the irradiated area.
The nurse performs a physical assessment of the precordium on an adult male. Identify where the nurse should place the stethoscope to auscultate the tricuspid area.
Located in the fifth intercostal space at the lower left of the sternal border; auscultate for S1.
The nurse in the outpatient clinic performs a physical assessment of a client. Identify the location where the nurse palpates the client's femoral pulse.
The femoral pulse is located below the inguinal ligament, midway between the symphysis pubis and the anterosuperior iliac spine.
The nurse in the outpatient clinic performs a physical assessment of a client. Identify the location where the nurse palpates the client's radial pulse.
The radial pulse is located along the radial bone on the thumb side of the inner wrist.