204 final

A LPN discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must selfhelp groups such as AA meet to be successful? A Trust B Growth C Belonging D Independence

c

A LPN/LVN cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma? A Abrasion B Fracture C Crush injury D Incisional laceration

c

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the LPN/LVN to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling

c

A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid? A) 2 cups of soup B) 1 quart of water C) 8 oz of ice chips D) 6 oz of tea

c

a nurse is preparing to transfer a client who has right-sided weakness from the bed to a chair. in what order should the nurse take the following actions to assist the client? 1. ask the client is he can bear weight 2. use the stand-pivot technique to move the client to the chair 3. position the chair on the left side of the bed 4. have the client sit and dangle his feet at the bedside

1 3 4 2

A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following findings should the nurse expect? A) Albumin level of 3 g/dL B) HDL level of 90 mg/dL C) Norton scale score of 18 D) Braden scale score of 20

a

In what position should the LPN/LVN place a client recovering from general anesthesia? A Supine B Side-lying C High Fowler E Trendelenburg

b

What clinical indicators should the LPN/LVN expect a client with hyperkalemia to exhibit? Select all that apply. A Tetany B Seizures C Diarrhea D Weakness E Dysrhythmias

c d e

When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A. Record the amount on the client's fluid output record. B. Encourage the client to increase oral fluid intake. C. Notify the health care provider of the findings. D. Palpate the client's bladder for distention

a

Which client is most likely to be at risk for spiritual distress? A. Roman Catholic woman considering an abortion B. Jewish man considering hospice care for his wife C. Seventh-Day Adventist who needs a blood transfusion D. Muslim man who needs a total knee replacement

a

Which snack food is best for the LPN/LVN to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices

a

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement? A. Encourage the client to see the clinic's grief counselor. B. Determine if the client has a family history of suicide attempts. C. Inquire about whether the life partner was suffering from AIDS. D. Consult with the health care provider about the client's need for antidepressant medications.

a

While instructing a male client's wife in the performance of passive rangeof-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the LPN/LVN implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.

a

a nurse is administering IV fluid to an older adult client. the nurse should perform which priority assessment to monitor for adverse effects? A. auscultate lung sounds B. measure urine output C. monitor blood pressure readings D. monitor serum electrolyte levels

a

a nurse is administering an otic medication to an older adult client. which of the following actions should the nurse take to ensure that the medication reaches the inner ear? A. press gently on the tragus of the client's ear B. pack a small piece of cotton deep into the cent's ear canal C. move the client's auricle down and back toward her head D. tilt the client's head backward for 5 min

a

a nurse is performing a peripheral vascular assessment for a client. when placing the bell on the stethoscope on the client's neck, she heads the following sound: audible vascular sound associated with turbulent blood flow. this sound indicates which of the following? A. narrowed arterial lumen B. distended jugular veins C. impaired ventricular contraction D. asynchronous closure of the aortic and pulmonic valve

a

a nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take? A. gently shake the container of medication prior to administration B. transfer the medication to a medicine cup C. place the client in a semi-fowlers position to medication administration D. verify the dosage by measuring the liquid before administering it

a

A nurse is planning care for a client who has had a stroke, resulting in aphasia and dysphagia. Which of the following tasks should the nurse assign to an assistive personnel (AP)? (Select all that apply.) A) Assist the client with a partial bed bath. B) Measure the client's BP after the nurse administers an antihypertensive medication. C) Test the client's swallowing ability by providing thickened liquids. D) Use a communication board to ask what the client wants for lunch. E) Irrigate the client's indwelling urinary catheter

a b d

a nurse is caring for a client who has tuberculosis. which of the following actions should the nurse take? (Select all that apply) A. place the client in a rom with negative pressure airflow B. wear gloves the assisting the client with oral care C. limit each visitor to 2 hour increments D. wear a surgical mask when providing client care E. use antimicrobial sanitizer for hand hygiene

a b e

A LPN/LVN is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. A Ask the client what is the client's acceptable level of pain. B Eliminate all activities that precipitate the pain. C Administer the pain medications regularly around the clock. D Use a different pain scale each time to promote patient education. E Assess the client's pain every 15 minutes

a c

The LPN/LVN is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. A Allergy to the medication B Itching in the ear canal C Drainage from the ear canal D Tympanic membrane rupture E Partial hearing loss in the affected ear

a c d

A LPN is teaching an adolescent about type 1 diabetes and selfcare. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. A "What is diabetes?" B "What will my friends think?" C "How do I give myself an injection?" D "Can you tell me how the glucose monitor works?" E"How do I get the insulin from the vial into the syringe?

a d

A nurse is planning to initiate IV therapy for an older adult client who requires IV fluids. Which of the following actions should the nurse take? A) Insert the IV catheter into the back of the client's hand. B) Massage the area of the venipuncture site vigorously. C) Insert the IV catheter without using a tourniquet. D) Apply traction to the skin proximal to the insertion site to stabilize the vein

c

A nurse is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the nurse take next? A) Rock the client up to a standing position. B) Pivot on the foot that is the farthest from the chair. C) Assess the client for orthostatic hypotension. D) Apply a gait belt to the client.

c

A nurse is teaching a client and his family how to care for the client's tracheostomy at home. Which of the following instructions should the nurse include in the teaching? A) Remove the outer cannula cautiously for routine cleaning. B) Use tracheostomy covers when outdoors. C) Use sterile technique when performing tracheostomy care at home. D) Cleanse irritated skin with full-strength hydrogen peroxide

b

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors

b

What type of interview is most appropriate when a LPN/LVN admits a client to a clinic? A Directive B Exploratory C Problem solving D Information giving

a

A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the LPN/LVN take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CRF

a

A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond? A. Ask him to rate his pain on a scale of 1 to 10. B. Encourage him to wait until bedtime so the pill can help him sleep. C. Attend to an acutely ill client's needs first because this client is laughing. D. Instruct him in the use of deep breathing exercises for pain control.

a

A nurse is admitting a client who has been having frequent tonic-clonic seizures. Which of the following actions should the nurse add to the client's plan of care? A) Wrap blankets around all four sides of the bed. B) Apply restraints during seizure activity. C) Place the client in a supine position during seizure activity. D) Have a tongue depressor at the client's bedside.

a

A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? A) Thread the IV catheter so that the hub rests at the insertion site. B) Shave excess hair from around the insertion site. C) Cleanse the site with hydrogen peroxide before IV catheter insertion. D) Palpate the site carefully just before inserting the IV catheter.

a

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds

a

A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take? A) Pad the client's wrist before applying the restraints. B) Evaluate the client's circulation once per shift after application. C) Remove the restraints every 4 hr to evaluate the client's status. D) Secure the restraint ties to the client's bed side rails

a

After completing an assessment and determining that a client has a problem, which action should the LPN/LVN perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.

a

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection? A. Mode of transmission B. Portal of entry C. Reservoir D. Portal of exit

a

The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift

a

An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the LPN must consider? Select all that apply. A Assessment of skin turgor B Documentation of vital signs C Assessment of intake and output D Administration of antiemetic drugs E Replacement of fluid and electrolytes

a d e

A LPN is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? A Albumin B Globulin C Thrombin D Hemoglobin

b

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the LPN/LVN to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area.

b

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the LPN advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner

b

A nurse is caring for a client who has a respiratory infection. Which of the following techniques should the nurse use when performing nasotracheal suctioning for the client? A) Insert the suction catheter while the client is swallowing. B) Apply intermittent suction when withdrawing the catheter. C) Place the catheter in a location that is clean and dry for later use. D) Hold the suction catheter with her clean, nondominant hand

b

A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vital signs every 15 min and call him back in 1 hr. From a legal perspective, which of the following actions should the nurse take next? A) Document the provider's statement in the medical record. B) Notify the nursing manager. C) Consult the facility's risk manager. D) Complete an incident report

b

A nurse is caring for a group of clients. Which of the following actions should the nurse take to prevent the spread of infection? A) Carry a client's soiled linens out of the room in a mesh linen bag. B) Place a client who has tuberculosis in a room with negative-pressure airflow. C) Provide disposable plates and utensils for a client who is HIV-positive. D) Dispose of a client's blood-saturated dressing in a trash bag inside a second trash bag

b

A nurse is initiating a protective environment for a client who has had an allogeneic stem cell transplant. Which of the following precautions should the nurse plan for this client? A) Make sure the client's room has at least 6 air exchanges per hour. B) Make sure the client wears a mask when outside her room if there is construction in the area. C) Place the client in a private room with negative-pressure airflow. D) Wear an N95 respirator when giving the client direct care.

b

A nurse is caring for a client who is receiving parenteral fluid therapy via a peripheral IV catheter. After which of the following observations should the nurse remove the IV catheter? A) Small air bubbles are in the IV tubing. B) IV flow stops when the client bends her arm. C) Swelling and coolness are observed at the IV site. D) Blood is visible in the IV catheter and tubing.

c

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take? A. Assign an unlicensed assistive personnel to transport the client via a wheelchair. B. Remind the client to walk carefully down the stairs until reaching a lower floor. C. Ask the client to help by assisting a wheelchairbound client to a nearby elevator. D. Open the closest fire doors so that ambulatory clients can evacuate more rapidly

b

During the initial physical assessment of a newly admitted client with a pressure ulcer, a LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? A The nurse also should have instituted a plan to increase activity. B The nurse provided supportive nursing care for the well-being of the client. C Debridement of the pressure ulcer should have been done before the dressing was applied. D Treatment should not have been instituted until the health care provider's prescriptions were received.

b

Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit.

b

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.

b

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used.

b

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward, underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair

b

When assisting an 82-year-old client to ambulate, it is important for the LPN/LVN to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet.

b

a nurse in a surgical suite notes documentation on a client's medical record that he has a latex allergy. in preparation for the client's procedure, which of the following precautions should the nurse take? A. ensure sterilization of non disposable items with ethylene oxide B. wrap monitoring cords with stockinette and tape them in place C. cleanse latex pots on IV tubing with chlorohexidine before injection medication D. wear hypoallergenic latex gloves that contain powder

b

a nurse is admitting a client who has influenza. which of the following types of transmission precautions hold the nurse initiate? A. airborne B. droplet C. contact D. protective environment

b

a nurse is caring for a client who asks about the purpose of advance directives. which of the following statements should the nurse make? A. "they allow the court to overrule an adult client's refusal of medical treatment." B. "they indicate the form of treatment a client is willing to accept in the event of a serious illness." C. "the permit a client to withhold medical information from heath care personnel." D. "they allow heath care personnel in the emergency department to stabilize a client's condition."

b

a nurse is caring for a client who has an NG tube and is receiving intermittent feedings through an open system. which of the following actions should the nurse take first? A. rinse the feeding bag with water between feedings B. tell the client to keep the head of the bed elevated at least 30º C. make sure the enteral formula is at room temperature D. wipe the top of the formula can with alcohol

b

a nurse is caring for a client who report pain. when documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? A. "I'm having mild pain." B. "the pain is like a dull ache in my stomach." C. "I notice that the pain gets worse after I eat." D. "the pain makes me feel nauseous."

b

a nurse is planning to insert a peripheral IV catheter for an older adult client. which of the following actions should the nurse plan to take? A. insert the other at a 45º angle B. place the client's arm in a dependent position C. shave excess hair from the insertion site D. initiative IV therapy in the veins of the hand

b

a nurse is reviewing protocol in preparation for suctioning secretions from client who has a new tracheostomy. which of the following actions should the nurse plan to take? A. use a resuscitation bag with 80% oxygen prior to the procedure B. select a suction catheter that is half of the size of the lumen C. place the end of the function catheter in water-soluble lubricant D. adjust the wall suction apparatus to a pressure of 170 mm Hg

b

a nurse manager is overseeing the care on a unit. which of the following should the nurse manager identify as a violation of HIPAA guidelines? A. a nurse who is caring for a client reviews the client's medical chart with the nursing student who is working with the nurse B. a nurse asks a nurse from another unit to assist with her documentation C. a nurse who is caring for a client returns a call to the client's durable power of attorney for health care designee to discuss the client's care D. a nurse discusses a client's status with the physical therapies that is caring for the client's bedside

b

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A. Steak, baked beans, and a salad B. Broiled fish, green beans, and an apple C. Pork chops, macaroni and cheese, and grapes D. Avocado salad, milk, and angel food cake

b cholecystitis requires a low fat diet

A nurse working in the emergency department is witnessing the signing of informed consent forms for the treatment of multiple clients during her shift. Which of the following individuals' signatures may the nurse legally witness? (Select all that apply.) A) A teacher who brings in a 7-year-old student B) A 16-year-old client who is married C) A 27-year-old client who has schizophrenia D) An adoptive parent who brings in his 8-year-old son E) A 17-year-old mother who brings in her toddler

b c d e

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply. A Difficulty in swallowing B Diminished sensation of pain C Heightened response to stimuli D Impaired hearing of high-frequency sounds E Increased ability to tolerate environmental heat

b d

a nurse is assessing an older adult client's risk for falls. which of the following assessments would the nurse use to identify the client's safety? A. lacrimal apparatus B. pupil clarity C. appearance of bulbul conjuctiva D. visual fields E. visual acuity

b d e

The LPN/LVN recognizes that which are important components of a neurovascular assessment? Select all that apply. A Orientation B Capillary refill C Pupillary response D Respiratory rate E Pulse and skin temperature F Movement and sensation

b e f

. The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You"

c

A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit? A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked. C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act.

c

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

c

The LPN is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase.

c

The LPN is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? A Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. B Develop a chart for the client, listing the times the medication should be taken. C Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. D Instruct the client and client's children to put medications in a weekly pill organizer

c

The LPN/LVN should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: A Force urine to back up into the kidneys. B Suppress production of urine. C Cause the device to pull away from the skin. D Tear the ileal conduit

c

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the LPN/LVN take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider.

c

The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take? A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents.

c

The triage LPN in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? A Multipara in active labor B Middle-aged woman with substernal chest pain C Older adult male with a partially amputated finger D Adolescent boy with an oxygen saturation of 91%

c

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted.

c

a nurse is caring for a client who requires bed rest and has a prescription for anti embolic stocking. which of the following actions should the nurse take? A. apply the stockings so the creases are on the front of the leg B. apply the stockings while the client's legs are in a dependent position C. remove the stockings at least once per shift D. remove the stockings while the client is sitting in a reclining chair

c

a nurse is evaluating a client's use of a cane. which of the following actions should the nurse identify as an indication of correct use? A. the top of the cane is parallel to the client's waist B. when walking, the client move the cane 46 cm (18 in) forward C. the client holds the cane on the stronger side of her body D. the client moves her stronger limb forward with the cane

c

a nurse is using an open irrigation technique to irrigate a client's indwelling urinary catheter. which of the following actions should the nurse take? A. place the client in a side-lying position B. instill 15 mL of irrigation fluid into the catheter with each flush C. subtract the amount of irritant used from the client's urine output D. perform the irrigation using a 20 mL syringe

c

Which age-related change should the LPN/LVN consider when formulating a plan of care for an older adult? Select all that apply. A Difficulty in swallowing B Increased sensitivity to heat C Increased sensitivity to glare D Diminished sensation of pain E Heightened response to stimuli

c d

A nurse on a medical unit is preparing to discharge a client to home. Which of the following actions should the nurse take as part of the medication reconciliation process? A) Seal unused hospital medications in a plastic bag. B) Evaluate the client's ability to self-administer medications. C) Report an identified discrepancy to The Joint Commission. D) Compare prescriptions with medications the client received during hospitalization.

d

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.

d

A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the LPN consider about how gamma globulin provides passive immunity? A It increases production of short-lived antibodies. B It accelerates antigen-antibody union at the hepatic sites. C The lymphatic system is stimulated to produce antibodies. D The antigen is neutralized by the antibodies that it supplies

d

A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match.

d

A nurse is assessing a client who reports increased pain following physical therapy. Which of the following questions should the nurse ask when assessing the quality of the client's pain? A) "Is your pain constant or intermittent?" B) "What would you rate your pain on a scale of 0 to 10?" C) "Does the pain radiate?" D) "Is your pain sharp or dull?

d

A nurse is caring for a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect? A) Numbness of the extremities B) Bradycardia C) Positive Chvostek's sign D) Abdominal cramping

d

A nurse is caring for a client who needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein? A) Oat cereal B) Refried beans C) Peanut butter D) Cheddar cheese

d

A nurse is planning teaching for a group of adolescents who each recently had surgical placement of an ostomy. Which of the following methods should the nurse use as a psychomotor approach to learning? A) Role play B) Group discussions C) Question-answer meetings D) Practice sessions

d

A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the LPN/LVN question? A Oral psyllium (Metamucil) B Oral potassium supplement C Parenteral half normal saline D Parenteral albumin

d

A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the LPN/LVN best handle this situation? A Tell the neighboring client to stop singing. B Close the doors to both clients' rooms at night. C Give the complaining client the prescribed as needed sedative. D Move the neighboring client to a room at the end of the hall

d

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the LPN/LVN implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request

d

Following a surgery on the neck, the client asks the LPN why the head of the bed is up so high. The LPN should tell the client that the high-Fowler position is preferred for what reason? A To avoid strain on the incision B To promote drainage of the wound C To provide stimulation for the client D To reduce edema at the operative site

d

To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the LPN should change the administration set every: A 4 to 8 hours B 12 to 24 hours C 24 to 48 hours D 72 to 96 hours

d

When being interviewed for a position as a registered professional LPN, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? A Negligence B Malpractice C Breach of duty D False imprisonment

d

Which intervention is most important for the LPN/LVN to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

d

Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation? A. Instruct in the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D. Encourage frequent ambulation in the hallway

d

Which nutritional assessment data should the LPN/LVN collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference.

d

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium

d

a nurse is caring for a client who has herpes zoster and asks the runs about the use of complementary and alternative therapies for pain control. the nurse should inform inform the client that his condition is a contraindication for which of the following therapies? A. biofeedback B. aloe C. feverfew D. acupuncture

d

a nurse is preparing to administer multiple medications to a client who has an enteral feeding tube. which of the following actions should the nurse plan to take? A. dissolve each medication in 5 mL of sterile water B. draw up medication together in the syringe C. push the syringe plunger gently when feeling resistance D. flush the tube with 15 mL of sterile water

d

Which nursing activities are examples of primary prevention? Select all that apply. A Preventing disabilities B Correcting dietary deficiencies C Establishing goals for rehabilitation D Assisting with immunization program E Stopping smoking

d e