K PN 2018 -3

The LPN/LVN cares for a client diagnosed with AIDS complaining of diarrhea. It is MOST important for the LPN/LVN to take which of the following actions? 1. Decrease roughage in the client's diet. 2. Encourage the client to eat three meals per day. 3. Instruct the client to increase intake of dairy products. 4. Inform the client to decrease fluid intake.

1. Decrease roughage in the client's diet. Strategy: "MOST important" indicates discrimination is required to answer the question. (1) CORRECT—avoid foods that stimulate intestinal motility, such as vegetables and fruits; fatty, spicy, and sweet foods; alcohol; and caffeine (2) small, frequent meals are better tolerated (3) lactose intolerance can contribute to diarrhea (4) drink lots of fluids, especially between meals

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." Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) CORRECT—Tylenol is contraindicated because it is hepatotoxic; instruct client to avoid all medications unless prescribed by the physician (2) alcohol damages liver cells (3) presence of bile salts in skin causes pruritus; instruct client to keep nails short; apply calamine lotion (4) instruct about the importance of personal hygiene; hand washing is the greatest preventive method for reducing the spread of infection; not related to headaches and hepatitis

The community health LPN/LVN assists a bedridden client to manage peripheral edema associated with heart disease. It is most important for the LPN/LVN to include which statement when instructing the client? 1. "Eat smaller feedings more frequently." 2. "Regular exercise plays an important role in reducing the retention of fluid in your body." 3. "Your legs swell more than the rest of your body because of the effects of gravity." 4. "If your feet are still swollen after a good night's sleep, the problem is related to the heart."

1. "Eat smaller feedings more frequently." Strategy: "MOST important" indicates that discrimination is required to answer the question. (1.) CORRECT— requires less effort to eat; offer foods that have a relatively soft texture and encourage client to eat slowly (2.) because peripheral edema is often related to kidney or cardiac disease, regular exercise does not contribute significantly to reduction in fluid volume (3.) true of ambulating client; bedridden client retains fluid near sacral area (4.) if peripheral edema is related to venous insufficiency, fluid in legs and feet may resolve during the night while the legs are at the same level as the heart

To determine their ability to manage prescribed medication therapy, the LPN/LVN schedules weekly home appointments for a group of psychiatric clients. The LPN/LVN learns that several clients recently lost family members. Which client should the nurse see first? 1. A client diagnosed with schizophrenia. 2. A client diagnosed with anxiety disorder. 3. A client diagnosed with mood disorder. 4. A client diagnosed with cognitive disorder.

1. A client diagnosed with schizophrenia. Strategy: "FIRST" indicates priority. (1) CORRECT—schizophrenic clients are thought to have a genetic predisposition to stress; stress is more likely to exhaust coping abilities, resulting in display of disequilibrium of the disease process; schizophrenics withdraw from relationships and from the world, have inappropriate or no display of feelings, are suspicious, and are not able to test reality (2) the most common psychiatric disorder; less likely to become significantly disabled than the schizophrenic client, who is likely to require hospitalization; anxiety is the feeling of dread or fear in the absence of an external threat or disproportionate to the nature of the threat (3) most clients do not require hospitalization when therapeutic interventions are initiated to stabilize the client (4) usually have decreased ability to interpret environmental stimuli; less likely to be affected by loss of family member than schizophrenic client is

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. trategy: "FIRST" indicates priority. (1.) CORRECT— can be drug-induced or related to cardiac hypoxia or cardiac damage; because any sign of pump failure could be life-threatening, needs to be addressed immediately; because etiology is not known, would need involvement of physician and complex assessment methods along with potentially complex interventions (2.) within normal limits; HDL levels are not as health-impairing as LDL (3.) although could become life-threatening, can be resolved by reapplying dressing without additional input from physician (4.) can develop sepsis, but no immediate life-threatening risks exist

The LPN/LVN learns a client has hyperglycemia, hypocalcemia, and hyperkalemia. The LPN/LVN notifies the supervising nurse of the possible need for which information? 1. Blood urea nitrogen (BUN), creatinine labs. 2. Bilirubin, alanine aminotransferase (ALT) labs. 3. Measurement of hourly intake and output. 4. Complete blood count (CBC).

1. Blood urea nitrogen (BUN), creatinine labs. Strategy: Think about each answer and how it relates to the lab values. 1) CORRECT — indicative of chronic kidney disease; kidneys are unable to retain calcium and unable to excrete potassium; chronic kidney disease is commonly associated with diabetes mellitus 2) fluctuation in both are associated with liver failure; ALT is also associated with heart disease 3) intake/output needs to be measured but not necessarily hourly; would not provide the specific data provided by BUN and creatinine 4) erythropoietin production can result in anemia; CBC does not provide adequate information needed for diagnosis

The LPN/LVN cares for a client after cataract surgery. Postoperative orders for the client state, "Apply pressure dressing, OS." Which action by the LPN/LVN is most appropriate? 1. Call the health care provider to verify the order. 2. Ask the health care provider if the dressings should be bilateral. 3. Apply the eye pad to the right eye and cover tightly with Elastoplast tape. 4. Ask the charge nurse to interpret the order.

1. Call the health care provider to verify the order. Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. (1.) CORRECT— pressure puts tension on the delicate suture lines, therefore is avoided (2.) will cause tension on suture line; not necessary to cover both eyes; would require more supervision by nursing staff (3.) OS is left eye (ocular sinister); should not apply pressure to area (4.) part of basic knowledge included in LPN/LVN studies

The LPN/LVN cares for a client diagnosed with Addison's disease. The LPN/LVN recognizes that which of the following is the BEST description of the client's skin? 1. Dark pigmented, leather-like in appearance. 2. Flushed, wet with perspiration, frequent itching. 3. Thin, fragile, with multiple bruises. 4. Skin is dry, scaly, and pale.

1. Dark pigmented, leather-like in appearance. Strategy: "BEST" indicates discrimination is required to answer the question. (1) CORRECT—Addison's disease causes an increase in the melanocyte-stimulating hormone, which results in an abnormal dark pigmentation of the skin (2) because of the increased metabolic rate, increased perspiration is seen with hyperthyroidism (3) occurs more commonly in Cushing's syndrome (4) occurs with hypothyroidism

A 48-year-old clinically depressed client is admitted to an inpatient unit. The LPN/LVN notifies the charge nurse that the laboratory and diagnostic test reports are available. The LPN/LVN identifies that which of the following findings would cause the health care provider to order an antidepressant for the client? 1. Elevated glucocorticoid levels with an enlarged limbic area. 2. Decreased glucose in the cerebrospinal fluid (CSF). 3. Electroencephalogram (EEG) shows less time spent in the rapid eye movement (REM) phase. 4. Increased serum thyroid-stimulating hormone (TSH).

1. Elevated glucocorticoid levels with an enlarged limbic area. Strategy: Think about each answer. (1) CORRECT—depressed clients tend to have high levels of hormones such as corticosteroids; fluctuations or spikes seem to occur more often, and spikes are higher than in other populations; structures involved in mood changes, such as limbic system, tend to be larger in the depressed client (2) increased glucose in CSF can indicate presence of bacteria (3) clients with clinical depression tend to spend more time in the REM phase and less in the deeper sleep cycle (4) hypothyroidism can cause slowed cognitive processes

An older client says to the LPN/LVN, "I know my spouse visited me today, but denies coming. What's going on? I'm so mixed up." Which is the best way for the LPN/LVN to handle this distortion of thinking caused by sensory alterations? 1. Encourage discussion of the client's "mixed-up" feelings. 2. Explain to the client that the spouse did not visit today. 3. Encourage the client's spouse to visit more frequently. 4. Explain that being "mixed up" is unimportant to the recovery.

1. Encourage discussion of the client's "mixed-up" feelings.

The LPN/LVN understands that it is MOST important to utilize which of the following principles when caring for a client immediately after being raped? 1. Focus on the here and now. 2. Ask the client about the needs for crisis counseling. 3. Determine how the rape occurred. 4. Assess how the client has previously responded to trauma.

1. Focus on the here and now. Strategy: Think about each answer. (1) CORRECT—first action is to assist client to identify her immediate needs and concerns (2) client will be referred for counseling; immediately after rape, LPN/LVN should help client identify immediate needs (3) will aid in prosecuting the perpetrator (4) focus on the client's immediate needs first; exploring how client responded to previous trauma is not helpful now

The LPN/LVN understands which food should be omitted from a client's diet before an electroencephalogram (EEG)? 1. Hot chocolate. 2. Orange juice. 3. Lemon sherbet. 4. Strawberry ice cream.

1. Hot chocolate. Strategy: Think about each answer. (1.) CORRECT—hot chocolate contains caffeine; beverages that contain caffeine are usually restricted 1 to 2 days before an electroencephalogram (EEG) (2.) withhold coffee, tea, and other stimulants; orange juice is not a stimulant (3.) lemon sherbet acceptable (4.) No reason to restrict ice cream prior to EEG

Which of the following nursing interventions by the LPN/LVN is MOST effective in promoting adequate nutrition for clients undergoing radiation and chemotherapy? 1. Include client's choices in meal and snack selection. 2. Ensure that meals are served hot. 3. Offer salty snacks every 2 hours. 4. Serve additional portions of food at mealtime.

1. Include client's choices in meal and snack selection. Strategy: Determine the outcome of each answer. Is it desired? (1) CORRECT—clients should be included in meal and snack selections as much as possible; assist clients to identify foods that are appealing; offer small, frequent feedings of nutrient-dense food (2) cold foods or foods served at room temperature are better tolerated than hot foods (3) do not offer client foods with empty calories; foods should be attractive and nutrient-dense (4) allow client to choose foods; appetite may decrease throughout day, so offer high-protein, high-calorie, nutrient-dense foods at breakfast

Because a client is admitted to an outpatient surgical clinic for an arthroscopic examination, it is MOST important for the LPN/LVN to take which of the following actions? 1. Inspect overlying skin for signs/symptoms of infection. 2. Determine the type of joint inflammation. 3. Place client in supine position on operating table. 4. Assess prior use of corticosteriods.

1. Inspect overlying skin for signs/symptoms of infection. Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) CORRECT—infections near the puncture site can place the client at risk for sepsis; because of the limited vascularity, bone infections are very difficult to manage (2) except for ankylosis, an arthroscopic examination can be performed on clients without regard to nature of the problem; assessment does not fall within the area of practice for the LPN/LVN (3) is proper position for procedure; assessment of site needs to be performed first (4) can delay healing, but risk of direct contact of microorganisms to site takes priority

The LPN/LVN understands the pain of angina is caused by which action? 1. Insufficient oxygen in the heart muscles. 2. Inflammation of the pericardium. 3. Ineffective contractions of the heart muscles. 4. Severe dysrhythmias.

1. Insufficient oxygen in the heart muscles. Strategy: Think about each answer. (1) CORRECT—angina pectoris is caused by ischemia of the myocardium related to coronary artery disease (2) describes pericarditis; symptoms include substernal chest discomfort that is worse on inspiration, pericardial friction rub, elevated white count; administer nonsteroidal antiinflammatory medication, assist client to find a comfortable position; assess for cardiac tamponade (3) describes heart failure (4) disturbances of electrical impulse formation and/or conduction may occur, but will be related to the hypoxia

The LPN/LVN understands that the goal of diet therapy for chronic kidney disease includes which? 1. Lowered intake of protein to decrease BUN. 2. Lowered intake of sugars to decrease blood glucose. 3. Lowered intake of fats to decrease blood triglycerides. 4. Lowered intake of amino acids to decrease triglycerides and serum albumin.

1. Lowered intake of protein to decrease BU Strategy: Think about each answer. (1) CORRECT—people with chronic kidney disease are in danger of increasing their blood urea nitrogen (BUN) due to the inability of their kidneys to secrete the by-products of protein metabolism (2) appropriate for a client diagnosed with diabetes; is not primary nutrient for chronic kidney disease (3) elevated triglycerides are a risk factor for coronary heart disease; not associated with chronic kidney disease (4) to decrease triglycerides, client should follow a diet low in saturated fats and eliminate alcohol

The LPN/LVN contributes to the care for a client admitted to the emergency department after an automobile accident. The client reports dizziness, and the health care provider suspects a head injury. The LPN/LVN should intervene if which behavior is observed? 1. The client leans forward with the head over the knees. 2. The client's neck is immobilized before being x-rayed. 3. The family members ask to remain with the client. 4. The nursing assistant sets up seizure precautions.

1. The client leans forward with the head over the knees. Strategy: "Should intervene" indicates something is wrong. (1.) CORRECT—clients with head injuries are treated as spinal cord injuries until x-rays are completed; need to obtain assistance to immobilize the client's neck should come before x-rays (2.) clients with head injuries are treated as spinal cord injuries until x-rays are completed; need to obtain assistance to immobilize the client's neck should come before x-rays (3.) clients are often comforted by the presence of family members; agitation should be kept to a minimum (4.) due to cerebral irritation, seizures often accompany head trauma

The LPN/LVN assists in the care of a client who had a femoropopliteal bypass graft 12 hours ago. The LPN/LVN should intervene if the nursing assistive person is observed doing which procedure? 1. The nursing assistive person sits the client in a chair for 30 min. 2. The nursing assistive person encourages the client to take sips of water. 3. The nursing assistive person accurately records intake and output. 4. The nursing assistive person encourages the client to cough and deep breathe every 2 hours.

1. The nursing assistive person sits the client in a chair for 30 min. Strategy: "Should intervene" indicates an incorrect action. (1) CORRECT—prolonged dependency of the extremity and leg crossing are contraindicated because of possible thrombus formation; monitor for adequate circulation and bleeding (2) appropriate action (3) because of the risks for fluid imbalance postoperatively, should measure I and O (4) appropriate action to prevent atelectasis

Using the Snellen test helps the LPN/LVN test for which vision problem? 1. Visual acuity. 2. Eye pressure. 3. Reading ability. 4. Peripheral vision.

1. Visual acuity. Strategy: Think about each answer. (1) CORRECT—visual acuity testing is accomplished by means of eye chart placed 20 ft from the client; a person able to read the chart from a distance of 20 feet has vision that is expressed as 20/20; numerator denotes the distance at which the test is conducted, and the denominator denotes the distance at which the smallest letters can be read by a person with normal (20/20) vision (2) intraocular pressure measured by tonometer (3) measures level of cognitive development (4) evaluated by a confrontational test; client faces examiner and looks directly into examiner's eyes; LPN/LVN moves object from a nonvisible field into the client's line of vision

The LPN/LVN interviews a 15-year-old boy. The nurse is MOST concerned if the adolescent states which of the following statements? 1. "Sometimes I feel really tired." 2. "I don't perspire like other kids." 3. "I can be a real klutz sometimes." 4. "I have two pimples on my forehead."

2. "I don't perspire like other kids." Strategy: MOST concerned" indicates something is wrong. (1) fatigue due to rapid growth (2) CORRECT—with adolescence there is an increase, not a decrease, in sweat production (3) problems of coordination related to rapid, unsynchronized growth of many systems (4) related to increased sebaceous gland activity

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." Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) judgmental (2) CORRECT—this is the best response, because it does not minimize the child's reaction; responds to the child's feeling tone and says that it will all be over soon (3) minimizes child's feelings; judgmental (4) false reassurance

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." Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. (1)does not identify that weight loss is normal for the newborn (2) CORRECT neonates can lose up to 10% of birth weight due to low levels of intake and excretion of fluids through lungs, bladder, and bowels; should regain weight by 10 to 14 days of age (3)weight loss is within normal limits (4)neonates excrete fluid but should only lose up to 10% of birth weight

he LPN/LVN assists in the care of a client with a new tracheostomy. The client's child asks the LPN/LVN why the health care provider performed a tracheostomy. Which explanation by the LPN/LVN is best? 1. "The tracheostomy promotes pulmonary function." 2. "The tracheostomy improves breathing capabilities." 3. "The tracheostomy prevents respiratory infections." 4. "The tracheostomy decreases respiratory tract secretions."

2. "The tracheostomy improves breathing capabilities." Strategy: "BEST" indicates discrimination is required to answer the question. (1) does not promote pulmonary function; if pulmonary function is poor, the tracheostomy is merely an artificial opening into the respiratory tract and will not improve the functioning (2) CORRECT—the main purpose of a tracheostomy is to provide and maintain an airway, permits the removal of tracheobronchial secretions when the client is unable to cough productively (3) does permit removal of tracheobronchial secretions, which decreases the chance of infection, but is not the primary reason a tracheostomy is performed; use aseptic technique (4) prevents aspiration of secretions

When intervening with a client who is in a state of crisis, which of the following statements by the LPN/LVN is MOST appropriate? 1. "Why do you feel so upset in this situation?" 2. "What have you done in the past when you felt this anxious?" 3. "There was no way to prevent this from happening." 4. "It seems as if this situation is very stressful for you."

2. "What have you done in the past when you felt this anxious?" Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1) "why" questions imply disapproval (2) CORRECT—helps the client utilize past experience to resolve or reduce current problems (3) LPN/LVN has no evidence to support this conclusion (4) reflective statement; during a crisis situation, more important to determine coping methods used in past

When assisting in the discharge teaching of a client with type 1 diabetes, the LPN/LVN informs the client that a sandwich made with two slices of whole wheat bread, one slice of bologna, 1 tsp of mayonnaise, and two lettuce leaves is the equivalent of which number of exchanges? 1. 1 bread exchange, 2 meat exchanges, 1/2 fat exchange, and 1 fruit exchange. 2. 2 bread exchanges, 1 meat exchange, 1 fat exchange, and 1 vegetable exchange. 3. 1 bread exchange, 2 meat exchanges, and 2 fat exchanges. 4. 2 bread exchanges, 1 meat exchange, 1 fat exchange, and 2 vegetable exchanges.

2. 2 bread exchanges, 1 meat exchange, 1 fat exchange, and 1 vegetable exchange. Strategy: Think about each answer. (1) Two slices of bread equals 2 bread exchanges; lettuce is a vegetable (2) CORRECT—according to the guidelines established by the American Diabetic Association, two slices of whole wheat bread equals 2 bread exchanges, one slice of bologna equals 1 meat exchange, 1 tsp of mayonnaise equals 1 fat exchange, two lettuce leaves equals 1 vegetable exchange (3) mayonnaise is the only fat exchange (4) lettuce is the only vegetable exchange

The LPN/LVN assists the nurse to develop a proposal for a research study to identify individuals most at risk for death by suicide. Which individual is the most appropriate research participant? 1. An adolescent with skin eruptions on the face. 2. A 50-year-old working part-time. 3. An 88-year-old living alone. 4. A single parent with four children.

2. A 50-year-old working part-time. Strategy: Think about each answer. (1) death by suicide has increased in the adolescent but is not as high as in the adult aged 45-64 years (2) CORRECT— individuals between the ages of 45-64 years have the highest death by suicide rate (3) individuals 85 years and older have the second highest suicide rate (4) individuals aged 25-44 have the fourth highest suicide rate

The LPN/LVN cares for a client diagnosed with end stage kidney disease and obsessive-compulsive disorder in the long-term care facility. The client has difficulty getting to dialysis on time because the client can't decide which clothing to wear. Which action by the LPN/LVN is most appropriate? 1. Place a clock in the client's room so that the client can monitor the time. 2. Allow the client to choose between two sets of clothing. 3. Inform the client that there will be 15 minutes to get dressed. 4. Dress the client in the appropriate clothing.

2. Allow the client to choose between two sets of clothing.

While preparing a 15-year-old female for the surgical removal of a lipoma, the LPN/LVN is told by the client that her 18-year-old boyfriend is physically abusive. Which of the following actions should the LPN/LVN take FIRST? 1. Discuss the matter with the client's parents without obtaining client's consent. 2. Consult with the supervising nurse. 3. Implement agency policy for prevention of family violence. 4. Notify hospital security immediately.

2. Consult with the supervising nurse Strategy: "FIRST" indicates priority. (1) is a process outside common activities for work area; need to confer before making decision (2) CORRECT—need to verify LPN/LVN role regarding addressing this issue by consulting with individual closer to policy setting (3) stay within chain of command; policies are often vague and applicable to many situations; need to confer with supervisor to determine the best pathway suited for the situation (4) currently, client does not appear to be at risk

The LPN/LVN understands which statement is true regarding anorexia nervosa? 1. Adolescent males are most affected. 2. Death occurs in 5 to 20% of anorexia clients. 3. Anorexia clients see themselves as emaciated. 4. Anorexia clients are self-indulgent.

2. Death occurs in 5 to 20% of anorexia clients Strategy: Think about each answer. 1) common in females 12 to 18 years old 2) CORRECT — anorexia is excessive fear of obesity, dramatic weight loss, distorted body image; 5 to 20% of anorexia clients die from self-imposed starvation and its sequelae, involving fluid-electrolyte imbalance and multiple organ system failure 3) have distorted body image 4) drastically reduce food intake and are preoccupied with foods that cause weight gain

The LPN/LVN expects the client to experience which of the following physiological changes during episodes of acute pain? 1. Decreased blood pressure. 2. Decreased skin temperature. 3. Decreased heart rate. 4. Decreased respiration.

2. Decreased skin temperature. Strategy: Think about each answer. (1)blood pressure and heart rate increase, which increases blood flow to brain and muscles (2) CORRECT—increased perspiration and vasoconstriction occur during acute pain episodes, thereby cooling off the skin (3)heart rate increases, resulting in increased cardiac output to meet the need for increased oxygen (O 2) (4)rapid, irregular respirations lead to increased oxygen supply to brain and muscles

The LPN/LVN examines the lymph nodes in the head and neck area of an older adult who is complaining of a sore throat. The nurse expects to find which of the following? 1. Increased number of lymph nodes. 2. Fewer lymph nodes than are found in younger populations. 3. Enlarged, hard lymph nodes. 4. Slightly enlarged, painless lymph nodes.

2. Fewer lymph nodes than are found in younger populations. Strategy: Think about each answer. (1.) number of nodes does not increase. (2.) CORRECT— because of natural tissue death, older adults have fewer nodes than younger populations; because of decreased function of immune system, nodes are not likely to enlarge (3.) do not expect nodes to be hard in relation to sore throat; more indicative of carcinoma (4.) may be slightly enlarged due to sore throat, but expect them to be sensitive; nonsensitive nodes suspicious of carcinoma

It is important for the LPN/LVN to observe early parent-infant interaction for which observation? 1. Proper parenting skills. 2. Healthy or pathological relationships. 3. Normal neurological functioning of the infant. 4. Parental knowledge of the infant's behavioral responses.

2. Healthy or pathological relationship. Strategy: Think about each answer. (1) proper parenting skills are important, but LPN/LVN should assess the parent-child interaction (2) CORRECT—observing the parents' behavioral responses to their newborn, including holding and interacting with the infant, gives some indication of a healthy or pathological response to the child; early observations by the LPN/LVN may also be used to identify infants at risk due to parental isolation, financial stress, or parental illness; referral to appropriate follow-up service may help lead to the establishment of a healthy parent-child relationship (3) not a part of the parent-infant interaction (4) appropriate, but assessing the parent-child interaction is most important

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. Strategy: "MOST appropriate" indicates discrimination is required to answer the question. (1.) places client at risk for aspiration; disease usually results in circulatory shock, blankets could decrease loss of body heat (2.) CORRECT— exhibiting signs/symptoms of Addisonian crisis; hypotension and hypoglycemia are common S/S; should perform these activities while having someone notify the supervising nurse of the client's change in status (3.) should act to reduce vomiting; Addisonian crisis is a life-threatening alteration; more important to eliminate or validate possible shock (4.) systemic response to sudden decrease in cortisol is more important than assessing contents of vomitus

The LPN/LVN observes a 5-year-old boy playing with several other children about his age. The LPN/LVN identifies which of these play activities as the one in which the child is MOST likely to engage? 1. Playing independently, but with the same toy as another child. 2. Playing with a toy telephone and imitating the doctor. 3. Playing doctor with another child. 4. Playing with a doctor doll.

2. Playing with a toy telephone and imitating the doctor. Strategy: "MOST likely" indicates discrimination may be required to answer the question. (1) characteristic of toddlers; preschoolers play is imitative, imaginative, and dramatic; will try to reproduce the behavior of adults close to them (2) CORRECT— children at 5 years of age are involved in imitative play; will play house, play doctor, or pretend to be engaged in the occupational role of the adults around them (3) age 5 is the beginning of cooperative play (4) 5-year-olds can run well, jump rope, dress without help, and tolerate periods of separation from parents

Immediately after a client's thoracentesis on the right side of the chest cavity, the LPN/LVN notices a progressive swelling on the right side of the client's chest and neck. The LPN/LVN identifies which of the following conditions as the MOST likely cause of this swelling? 1. Pneumothorax post-thoracentesis. 2. Subcutaneous emphysema. 3. Lipoma. 4. Hematoma formation.

2. Subcutaneous emphysema. Strategy: "MOST likely" indicates that discrimination is required to answer the question. (1) although uncommon, client is at risk for pneumothorax; primary signs/symptoms include sudden chest pain, dyspnea, asymmetrical chest movement (2) CORRECT—subcutaneous emphysema is a complication of thoracentesis in which air leaks into subcutaneous tissue and causes swelling; as more air enters the tissue, the swelling progresses (3) lipoma is a fatty tumor; signs and symptoms depend on location (4) swelling related to hematoma likely to appear red or purple, indicating bleeding in the area; less common than pneumothorax and subQ emphysema

A 7-year-old girl comes to the clinic for a checkup. The LPN/LVN weighs her and finds the child has gained 2.5 pounds (1.13 kg) during the previous 12 months. Which interpretation by the LPN/LVN about the child's weight gain is correct? 1. The weight gain is normal. 2. The child is not gaining enough weight. 3. The child is gaining too much weight. 4. The child is growth retarded.

2. The child is not gaining enough weight. Strategy: Think about each answer. 1) a school-age child should gain about 4.5 to 6.5 pounds per year 2) CORRECT — it is characteristic of the school-age child to have a rapid gain in weight with a slower increase in height; 2.5 pounds in 1 year is not an adequate weight gain 3) child has inadequate weight gain 4) the child should grow about 2 inches per year; not enough information to make this determination

The LPN/LVN assists in the care of a client diagnosed with esophageal diverticula. The LPN/LPN determines that care of this client is effective if which is observed? 1. The client's stool specimen is negative for occult blood. 2. The client gained 4 pounds during the previous 30 days. 3. The client has decreased signs/symptoms of inflammation/infection. 4. The client has decreased episodes of pyrosis.

2. The client gained 4 pounds during the previous 30 days. Strategy: Look for a positive outcome. (1) more commonly associated with PUD (peptic ulcer disease); indications include pain 2-3 hours after meals; food intake relieves the pain (2) CORRECT—primary problem is dysphagia, resulting in inadequate food intake; primary goal is to increase nutritional status; diverticula is saclike outpouching of the lining of the GI tract that goes through the muscle layer (3) can become inflamed if food is trapped in the sac; dysphagia is a problem clients commonly experience (4) heartburn; more commonly associated with gastric-esophageal reflux disease (GERD)

The LPN/LVN observes a student nurse (RN) add IV solution to the existing tubing of a client's IV. The LPN/LVN should intervene if which action is observed? 1. The student matches the bag label with the original orders. 2. The student starts to mark the time on the IV bag with a permanent marker. 3. The student inserts the tubing with the bag hanging. 4. The student checks the venipuncture insertion site.

2. The student starts to mark the time on the IV bag with a permanent marker. Strategy: "Should intervene" indicates a complication. (1) checking the order is first step before changing the IV bag (2) CORRECT— can puncture bag and contaminate the solution; use time tape (3) tubing can be inserted with bag inverted or upright (4) should check the site before adding the solution to the tubing; if is infiltrated, prescriber may choose to discontinue

The LPN/LVN assists in the care of a postoperative client with a nasogastric tube. Which of the following observations by the LPN/LVN is MOST reliable to determine proper positioning of the tube? 1. Absence of respiratory distress. 2. pH of aspirate is 3.6. 3. The tubal markings indicate the correct length remains visible just outside the nares. 4. The tube is securely taped.

2. pH of aspirate is 3.6. Strategy: "MOST reliable" indicates that discrimination is required to answer the question. (1)indicates no impairment of the respiratory tract but does not necessarily indicate tube was inserted in the gastric vault (2) CORRECT—aspirate for gastric contents and check pH; pH of gastric aspirate is 4 or less (3)can mark the tube as a guide but more reliable to check pH of gastric aspirate (4)does not indicate to the LPN/LVN that the tube is in the stomach

The LPN/LVN assists in the management of the home care of a client diagnosed with aplastic anemia. The LPN/LVN determines that further teaching is necessary if the client states which of the following? 1. "I should not eat fresh salads or unpeeled fruit." 2. "I should report any unusual bleeding." 3. "I grow my own vegetables in my garden." 4. "I will use the incentive spirometer every 4 hours during the day."

3. "I grow my own vegetables in my garden." Strategy: "Further teaching is necessary" indicates incorrect information. (1) prevents infection; aplastic anemia causes decrease or damage to bone marrow stem cells; causes neutropenia and thrombocytopenia (2) common sign/symptom includes reduced platelets due to bone marrow malfunction (3) CORRECT client should not garden due to decreased white blood cells (4) because aplastic anemia is failure of bone marrow function, platelets, RBCs, and WBCs are reduced; appropriate action; should avoid crowds and people with infection

The LPN/LVN instructs a client diagnosed with eczema about the appropriate diet. The LPN/LVN should intervene if the client states which of the following? 1. "Fish, nuts, and chocolate are my favorite foods." 2. "I eat strawberries, tomato, and apples every day." 3. "I have milk, wheat cereal, and scrambled egg whites for breakfast." 4. "I include soybeans, orange juice, and egg yolks in my diet."

3. "I have milk, wheat cereal, and scrambled egg whites for breakfast." Strategy: All parts of the answer have to be correct. (1)eczema is an inflammatory rash caused by allergic immune response; nuts commonly cause anaphylactic reaction; other foods do not (2)berries can cause anaphylactic reaction; the other foods are known to do so (3) CORRECT—are all common allergens associated with eczema (4)some legumes can cause an anaphylactic reaction; eggs are a common allergen

The LPN/LVN cares for a client after the physician performed a sigmoid colostomy due to cancer. The LPN/LVN assists the ostomy nurse in teaching the client how to care for the stoma. The LPN/LVN determines that teaching is successful if the client makes which of the following statements? 1. "I will drape the area and wash the stoma with hexachlorophene soap." 2. "I will clean the stoma vigorously with alcohol wipes and pat dry." 3. "I will clean around the stoma with soap and water and pat dry." 4. "I will drape the area and cleanse the stoma with povidone-iodine."

3. "I will clean around the stoma with soap and water and pat dry. Strategy: "Teaching is successful" indicates correct information. (1) too drying, which will cause irritation (2) pat dry gently or use hairdryer on cool setting to dry skin; alcohol too drying; avoid moisturizing soaps because lubricant interferes with the appliance adhering to the skin (3) CORRECT—provides adequate cleaning with limited irritation; observe for skin breakdown (4) too irritating to mucous membranes

A patient recovering from a laparoscopic laser cholecystectomy says to the LPN/LVN, "I hate the thought of eating a low-fat diet for the rest of my life." Which of the following responses by the LPN/LVN is MOST appropriate? 1. "I will ask the supervising nurse to come talk to you." 2. "What do you think is so bad about following a low-fat diet?" 3. "It may not be necessary for you to follow a low-fat diet for that long." 4. "At least you will be alive and not suffering that pain."

3. "It may not be necessary for you to follow a low-fat diet for that long." Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1.) LPN/LVN able to respond to the patient (2.) does not respond directly to the patient's statement (3.) CORRECT— fat restriction is usually lifted as the patient tolerates fat; biliary ducts dilate sufficiently to accommodate bile volume that was held by the gallbladder (4.) nontherapeutic and judgmental

The LPN/LVN in the well-child clinic is counseling the parent of a newborn about normal growth and development. The LPN/LVN determines that teaching is effective if the parent makes which statement? 3. "My baby should double his birth weight in 5 months." 4. "My baby should double his birth weight in 12 months."

3. "My baby should double his birth weight in 5 months. Strategy: "Teaching is effective" indicates correct information. (1) should gain 5 to 6 oz weekly for first 6 months (2) should gain 5 to 6 oz weekly for first 6 months (3) CORRECT—infants should double birth weight in 5 months (4) should triple birth weight in 12 months

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. Strategy: "MOST important" indicates discrimination is required to answer the question. (1) polycythemia is an increased volume of red blood cells; because of the increased number of RBCs, client is at risk for clot formation; vigorous massage is contraindicated (2) because of excessive RBCs, client will have reduced oxygen exchange, resulting in fatigue, intermittent claudication, and dyspnea; extensive exercise is contraindicated (3) CORRECT—increased histamine release related to the increased production of basophils results in generalized pruritus, a common discomfort (4) because of increased viscosity, client is at risk for clotting formation, resulting in a CVA or an MI, but no need to measure vital signs unless client exhibits signs/symptoms of circulatory impairment

The LPN/LVN cares for a client during a cholecystogram. Which action best prepares the client for the procedure? 1. Force fluids. 2. Insert a nasogastric tube. 3. Assess tolerance of fatty foods. 4. Administer an antiemeti

3. Assess tolerance of fatty foods. Strategy: "BEST" indicates discrimination may be required to answer the question. (1) fluids not offered during test; should take radiopaque tablets with a full glass of water the evening before the test (2) gastric decompression not required (3) CORRECT—high-fat meal needs to be ingested in x-ray department after fasting x-rays taken; more x-rays taken at intervals to determine how fast the gallbladder expels the dye; inability or refusal to ingest the meal will prevent completion of the test (4) if client vomits prior to the test, report to health care provider; hypermotility will prevent tablets from being absorbed

The LPN/LVN cares for a client immediately after a cardiac catheterization. It is MOST important for the LPN/LVN to take which of the following actions? 1. Monitor the client's temperature. 2. Observe the client for dysrhythmias. 3. Check the client's extremities for pulses. 4. Encourage the client to cough and deep breathe.

3. Check the client's extremities for pulses. Strategy: "MOST important" indicates discrimination is required to answer the question. (1) cardiac catheterization used with angiography to identify coronary artery disease and cardiac valvular disease; obtaining client's vital signs is an assessment and should be evaluated every 15 min for the first hour, every 30 min for next hour, and then hourly for next 3 h (2) will be attached to cardiac monitor with data easily obtained by any staff member; hemorrhage signs/symptoms will be more subtle as well as procedure placing client at risk for hemorrhage; does not necessarily place client at greater risk for dysrhythmias than for hemorrhage (3) CORRECT—following catheterization, trauma to the vessels used for catheterization is the major concern (4) can prevent respiratory impairment related to immobility during procedure as well as decreased depth of respiratory related to administration of analgesics; not primary concern immediately after procedure

While teaching a new mother how to change the diaper of her newborn, the LPN/LVN hears a "clunk" when the mother pushes the infant's legs forward to position the fresh diaper under its hips. The LPN/LVN knows this is indicative of which of the following? 1. The mother's lack of knowledge about how to gently handle the baby. 2. Juvenile idiopathic arthritis. 3. Developmental hip dysplasia. 4. Hypocalcemia.

3. Developmental hip dysplasia. Strategy: Think about the answers. (1) sounds from joints in response to the mother's handling of the newborn are not likely unless pressure or force is extremely strong (2) onset of this disease is more likely to occur at the age of 12 months (3) CORRECT—describes Ortolani's sign; palpable click with reduction in abduction and dislocation in adduction; subluxation will also be noted (4) is more apt to exhibit central nervous system signs/symptoms such as tetany, tremors, or seizures

A client informs the LPN/LVN that she discovered some soft and movable masses in both breasts that tend to become enlarged during menstruation. The LPN/LVN is aware that the client is most likely describing which of the following? 1. Cancer of the breasts. 2. Fibroids of the breasts. 3. Fibrocystic disease of the breasts. 4. Hyperplasia of the breasts.

3. Fibrocystic disease of the breasts. Strategy: Think about each answer. (1.) single, small, painless lump; firm and nonmobile; puckering, dimpling, nipple retraction or discharge (2.) fibroids are benign tumors occurring in the uterus or on the endometrial lining (3.) CORRECT— fibrocystic disease of the breasts involves benign cysts of the breast; present as soft, tender, freely moving cysts that become enlarged during menstruation; are usually bilateral (4.) not generally associated with menstruation

While an LPN/LVN is teaching family members how to manage tube feeding for an infant, the family receives notice that a 22-year-old son/brother in the military in another country is missing in action. The MOST appropriate intervention by the LPN/LVN for this family is which of the following? 1. Recommend that the family try to go about their normal business. 2. Suggest the family members contact appropriate authorities frequently. 3. Gather the family for a family conference to establish plans for caring for the infant and monitoring new information about missing family member. 4. Discuss how the family will cope if the family member missing in action is not found alive.

3. Gather the family for a family conference to establish plans for caring for the infant and monitoring new information about missing family member. Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) ignores the family's needs (2) keeps family in constant state of extreme anticipation and disappointment; although will be difficult, is best to structure contact times (3) CORRECT—planning conference can prevent family members from becoming exhausted; allows family to build on strengths during time of crisis (4) focus on the here and now; too early to discuss actions to take if the missing family member does not survive

A 3-year-old boy is diagnosed with hemophilia. Neither of the parents had the disease. Which statement by the LPN/LVN describes the hemophilia trait? 1. Hemophilia is an X-linked recessive trait found primarily in females. 2. Hemophilia is an X-linked dominant trait found primarily in females. 3. Hemophilia is an X-linked recessive trait found primarily in males. 4. Hemophilia is an X-linked dominant trait found primarily in males.

3. Hemophilia is an X-linked recessive trait found primarily in males. Strategy: Think about each answer. (1) hemophilia is a group of bleeding disorders in which there is a deficiency of one of the clotting factors; manifested by prolonged bleeding time with subcutaneous and intramuscular hemorrhage (2) treatment includes factor VIII concentrate and DDAVP (3) CORRECT—this trait very rarely shows itself in females because their second sex chromosome is also an X; they would need to have the trait linked to both chromosomes in order to show the disease; because males' second sex chromosome is a Y, they will show the disease; a female who has the trait linked to one X chromosome and not the other is considered a carrier (4) is X-linked recessive trait requiring each X chromosome to carry the trait; males have only one X chromosome, so if it affected, the trait is shown

The LPN/LVN cares for a client with a nasogastric (NG) tube attached to low suction. The previous shift reports the client had a high volume output the last 4 hours of the shift. It is most important for the LPN/LVN to instruct the nursing assistive person to perform which activity? 1. Apply oil-based lubricant to nostril. 2. Perform minimal morning hygiene activities. 3. Obtain vital signs every hour. 4. Assist the client with ambulation.

3. Obtain vital signs every hour. Strategy: Gather data before implementing. (1) water-based lubricant is recommended; oil-based can reduce tape adherence; oil-based molecules can be inhaled and result in an aseptic pneumonia (2) dehydration can result in fatigue; minimizing activities until problem is resolved could reduce degree of fatigue; reducing fatigue is not as threatening as the risk to vital organs (3) CORRECT—data provide a more precise estimate of client status; observe for indications of fluid volume deficit (4) dizziness can accompany dehydration, especially if occurs rapidly; will need assistance with ambulation; is more important to determine client status; changes in vital signs may indicate ambulation should be delayed

A client is admitted to the hospital with a diagnosis of paranoid schizophrenia. The LPN/LVN learns the client has not slept for 4 nights. When implementing the client's plan of care, the LPN/LVN should first try to achieve which goal? 1. Increase client's sense of responsibility. 2. Increase client's independence. 3. Promote client's trust. 4. Promote client's rest.

3. Promote client's trust. Strategy: "FIRST" indicates priority. (1) have to intervene first with schizophrenic's lack of trust because the schizophrenic views the world as hostile and threatening (2) since client is likely to be fearful, will lack confidence to perform activities independently (3) CORRECT—schizophrenic individuals are highly sensitive to fear of rejection; promoting trust is the nursing approach that should take priority (4) schizophrenic client not likely to rest until he feels safe

On the third postoperative day, a client with a left mastectomy incision continues to request analgesia for incisional pain q 3-4 hours. The LPN/LVN observes the incision and determines that normal healing is occurring. Which response by the LPN/LVN is best? 1. Palpate the wound area to express trapped drainage. 2. Request referral for a psychiatric consultant. 3. Provide the client opportunity to express feelings about the surgery. 4. Inform client an analgesic is not needed.

3. Provide the client opportunity to express feelings about the surgery Strategy: Determine the outcome of each answer. Is it desired? (1) normally performed by the surgeon (2) not enough information to make this judgment; should continue to talk with the client and then the LPN/LVN will consult with the supervising nurse (3) CORRECT—with physical impairments eliminated, may be using analgesia to postpone dealing with emotional response to surgical procedure as well as a life-threatening health alteration (4) not the best response; indicates may be using analgesia to consciously or unconsciously to deny or escape the situation; further assessment is needed

Which of the following actions is essential for the LPN/LVN to take after administering preoperative medication to a client? 1. Ensure that the operative permit is signed. 2. Discuss the client's feelings about surgery. 3. Raise the side rails of the bed. 4. Tell the client what to expect in the operating room.

3. Raise the side rails of the bed. Strategy: "Essential" indicates that discrimination is required to answer the question. (1)operative permit should be signed before preoperative medication is administered; otherwise client would be impaired and incapable of signing the permit (2)safety takes priority over psychosocial needs (3) CORRECT—because preoperative medications often include sedatives or narcotics, client will be impaired after the injection; will prevent injury to the client (4)one condition necessary for teaching/learning is to have an alert student; if preoperative medication is administered before teaching, client would be impaired and unable to learn

The LPN/LVN understands that according to Maslow hierarchy, which needs are most basic to any client's health maintenance plan? 1. Love and belonging. 2. Esteem and recognition. 3. Safety and security. 4. Self-actualization.

3. Safety and security. Strategy: Think about each answer. 1) the basic needs have to be met first; the most basic needs are the physiological needs (oxygen, food, water, etc.); if the basic needs are not met, the client will die; working on love and belonging occurs after the basic needs are met 2) client has positive self-esteem and the recognition of others; this level occurs after mastering love and belonging 3) CORRECT — the client establishes stability and consistency in life; is mostly psychological; if client does not feel safe, there is no energy for other pursuits 4) highest level; client becomes everything that the client is capable of becoming

The home care LPN/LVN provides care for a client with a fractured humerus due to a fall in the home. Which of the following observations requires an immediate intervention? 1. The bathroom is equipped with grab bars. 2. Throw rugs have been removed. 3. The client ambulates wearing socks. 4. The stairs are well lighted.

3. The client ambulates wearing socks Strategy: "Requires an immediate intervention" indicates something is wrong. (1)considered safe environmental structures (2)because clients can trip over the edges of rugs or rugs can slip, resulting in accidental injuries, throw rugs should have nonskid backing or be removed (3) CORRECT—should wear shoes or slippers with nonskid surfaces (4)ensure that there is adequate lighting on stairs; many falls at the top step and at the bottom step of stairs

The LPN/LVN assists in the care of a client after a total hip replacement due to degenerative joint disease (DJD). The LPN/LVN should intervene if which observation is made? 1. The client uses an incentive spirometer every 2 hours. 2. The client is positioned with a pillow between the legs. 3. The client is positioned with heels on the bed and toes pointed upward. 4. The client moves slowly when getting out of bed.

3. The client is positioned with heels on the bed and toes pointed upward. Strategy: "Should intervene" indicates a complication. (1.) prevents atelectasis and pneumonia (2.) prevents dislocation of the prosthesis (3.) CORRECT—elderly are prone to pressure sores; keep heels off bed to prevent pressure sores; pressure sores occur when soft tissue is trapped between a hard surface and a bony prominence (4.) reduces safety risks associated with orthostatic hypotension

The LPN/LVN obtains a client's blood pressure in the outpatient clinic. The client expresses concern about her 17-year-old son's sleeping all the time, his increased complaints of fatigue, and his irritable behavior. Which of the following responses by the LPN/LVN is BEST? 1. "How is this behavior affecting the rest of the family?" 2. "Teenagers usually require a lot of sleep." 3. "Restlessness and irritability are a part of the adolescent phase." 4. "Consider scheduling an appointment to have his blood level checked."

4. "Consider scheduling an appointment to have his blood level checked." Strategy: "BEST" indicates that discrimination may be required to answer the question. (1.) if behavior is significantly disruptive, impact on family unit needs to be addressed; initial focus should be on health and welfare of the child; client expresses concern; nurse should initiate problem-solving (2.) during early adolescence, the body needs more sleep than in childhood and young adulthood; gradual increase in fatigue and irritability points toward more than a need for sleep (3.) progressive fatigue unrelieved by rest indicates a possible underlying problem (4.) CORRECT— diet of fast food and soft drinks results in deficiency of iron; anemia is a common problem during adolescence, resulting in hypoxia that results in fatigue and irritability

The LPN/LVN in the outpatient clinic assists with an assessment on a client diagnosed with mastoiditis. The client reports experiencing chills, fever, nausea/vomiting, and a stiff neck. Which response is most appropriate? 1. "How high has the fever been?" 2. "How long have you had an elevated temperature?" 3. "What medication are you currently taking?" 4. "I need to have the charge nurse check you."

4. "I need to have the charge nurse check you." Strategy: "MOST appropriate" indicates that discrimination is required to answer the question. (1.) degree of fever is not significant; will not aid in meeting client's immediate needs (2.) period has had fever is not significant; current status should take priority (3.) data is needed to aid in planning care; is not the FIRST priority (4.) CORRECT—mastoiditis is secondary to otitis media; chills, fever, nausea, vomiting, and a stiff neck are all signs and symptoms of a spread of the infection to the brain, which can occur as a result of untreated or inadequately treated mastoiditis; should take actions to meet client's immediate needs

The LPN/LVN teaches a wellness class to a group of high school students. The LPN/LVN should intervene if a student makes which of the following statements? 1. "HIV is transmitted by sexual contact with an infected person." 2. "HIV can be transmitted by the sharing of needles." 3. "A breastfeeding mother who has HIV can infect her baby." 4. "I'm not going to use public toilets ever again."

4. "I'm not going to use public toilets ever again." Strategy: "Should intervene" indicates incorrect information. (1) can be spread through exposing mucous membranes to infected semen or vaginal secretions (2) if needle is contaminated with infected blood (3) HIV can be transmitted through the placenta, on contact with maternal blood or body fluids during birth, and through breast milk of an infected woman (4) CORRECT—casual contact cannot spread HIV

The LPN/LVN is assigned to care for a client diagnosed with type 2 diabetes. It is most important for the LPN/LVN to include which statement when reinforcing teaching for the client? 1. "Notify the dietitian if you have problems with your diet." 4. "Report visual changes right away."

4. "Report visual changes right away." Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) although LPN/LVNs can teach clients about their diets, the interdisciplinary approach works best when providing care for clients with complex health problems (2) clients often have difficulty omitting desserts made with refined sugar from their diets; offering alternatives is relevant but is not as significant as having client report irreversible complications in a timely manner (3) because of the decrease in production of WBC in diabetes, which reduces the ability to combat infectious processes, diabetics need to avoid people with URI; though prolonged, clients can recover from URI (4) CORRECT—client needs to be aware of the complication diabetic retinopathy; which is irreversible, yet preventable; causes of type 2 diabetes include obesity, heredity, or environmental factors; treatment includes weight reduction, diet, exercise, and oral antidiabetic agents

The LPN/LVN observes a child walk up and down steps. The nurse notes the child has a steady gait and can use short sentences. The nurse would estimate the child's age to be which of the following? 1. 6 months. 2. 12 months. 3. 14 months. 4. 24 months.

4. 24 months. Strategy: Think about each answer. (1) can roll over from stomach to back; early ability to distinguish and recognize strangers (2) needs help walking; eats with fingers; says three to five words other than "dada" and "mama" (3) walks without help; kneels without support; says four to six words including names (4) CORRECT—goes up and down stairs alone, runs well with wide stance, builds tower of six to seven blocks, has vocabulary of about 300 words

A client diagnosed with obsessive-compulsive disorder tells the LPN/LVN of being afraid about contracting AIDS. The client spends much of the day washing hands and spraying disinfectant in the room. The LPN/LVN understands that the client's hand-washing behavior represents which thought process? 1. A drive that needs to be denied. 2. A dissociative response to trauma. 3. A hidden wish to become ill and disabled. 4. A symbolic expression of conflict and guilt.

4. A symbolic expression of conflict and guilt. Strategy: Think about each answer. (1) drive is an internal or external stimulus that motivates the individual; obsession is repetitive, uncontrollable thought; compulsion is repetitive, uncontrollable action (2) dissociation disconnects one part of memory from another; client is associating cleanliness with prevention of AIDS (3) hypochondriasis is being overly concerned about one's health (4) CORRECT—repetitive behaviors are attempts to control anxiety; clients have a need to control themselves, others, or their environments

he outer cannula of a client's tracheostomy tube is accidentally expelled 36 hours after surgery. Which action should the LPN/LVN take first? 1. Contact the health care provider immediately. 2. Cut the tracheostomy neck ties. 3. Notify the supervising nurse. 4. Use manual resuscitation bag to ventilate client.

4. Use manual resuscitation bag to ventilate client. Strategy: "FIRST" indicates priority. (1) will eventually need to notify health care provider; currently client is in need of oxygen; unless the health care provider is readily available, this intervention does not match the urgency of the client needs (2) should focus on providing source of oxygen to client (3) should provide oxygenation for client while notifying supervising nurse (4) CORRECT—LPN/LVN should use manual resuscitation bag to ventilate client while another staff member contacts the resuscitation team; tube insertion is not part of LPN/LVN role

The LPN/LVN cares for a client diagnosed with a fractured right hip. The client's lab values include: Hgb 15, HCT 46%, sodium 140 mEq/L, potassium 5.6 mEq/L, and chloride 100 mEq/L. It is most important for the LPN/LVN to monitor for which client change? 1. A weight gain of 2 lb in 1 day. 2. An increase in nausea. 3. An increase in muscle irritability. 4. An episode of fibrillation.

4. An episode of fibrillation. Strategy: "MOST important" indicates discrimination is required to answer the question. (1) indicates client is retaining fluid, could eventually result in a threat to cerebral status and respiratory status (2) because neuromuscular function is the primary function of KCl, hyperkalemia often causes nausea because of the impact on smooth muscle contraction, gastric emptying, and paralytic ileus; change in cardiac status takes priority (3) hyperkalemia causes muscle weakness and paralysis (4) CORRECT—normal potassium is 3.5 to 5.0 mEq/L; hyperkalemia causes fibrillation or ventricular dysrhythmias that can result in an immediate significant reduction in cardiac output and coronary circulation; is life-threatening and must be treated immediately

A client undergoes a mastoidectomy. The client has difficulty drinking without drooling after returning to the unit. It is most important for the LPN/LVN to take which action? 1. Reassure the client that this is a common postoperative problem that will disappear in a few days. 2. Tell the client rest is important at this time because of tiredness. 3. Loosen the dressing on the affected ear. 4. Assess the client's ability to whistle.

4. Assess the client's ability to whistle. Strategy: "MOST important" indicates that discrimination is required to answer the question. (1.) because of location of surgical site, risk of damage to the facial nerve (cranial nerve II) exists; drooling may be due to neuromuscular dysfunction; needs further assessment (2.) if drooling is a new sign/symptom, should link to surgical procedure (3.) a dressing that results in pressure sufficient to impair neural status would have to be extremely tight; would involve more than one particular nerve (4.) CORRECT—the ability to whistle tests for the postoperative complication of facial nerve paralysis

A health care provider prescribes levothyroxine (Synthroid) 50 mcg po daily for an elderly client. It is MOST important for the LVN/LPN to include which of the following instructions to the client? 1. Ingest medication with food. 2. Report for serum thyroxine level after 7 days. 3. Return after 10 days for thorough cardiac workup. 4. Avoid excessive exercise.

4. Avoid excessive exercise. Strategy: "MOST important" indicates discrimination may be required to answer the question. (1) taking on empty stomach is recommended; levothyroxine (Synthroid) is hormone replacement; side effects include nervousness, tremors, insomnia, tachycardia, palpitations, dysrhythmias, and angina (2) therapeutic effectiveness occurs after several weeks (3) because drug increases basal metabolic rate (BMR), it can have adverse effects such as tachycardia, dysrhythmia, hypertension; testing is recommended before initiating treatment; is especially true with older adults (4) CORRECT—stressors such as exercise, infection, or surgery can cause a life-threatening exacerbation; onset of drug is 3-4 weeks; should wait until drug becomes effective

The LPN/LVN understands that essential hypertension is caused by which reason? 1. A high-salt diet. 2. Kidney disease. 3. Obesity. 4. Cause is unknown.

4. Cause is unknown. Strategy: Think about each answer. (1) an associated risk factor for developing essential hypertension; other risk factors include family history of hypertension, physical inactivity, excessive alcohol intake (2) kidney disease is a cause of secondary hypertension (3) obesity is an associated risk factor for developing essential hypertension; many obese individuals do not have HTN (4) CORRECT—essential (primary) hypertension accounts for 90 to 95% of all cases; hypertension may have no symptoms or headache, dizziness, anginal pain; treatment includes medication and lifestyle changes

The LPN/LVN assists the occupational nurse in constructing a long-term health program for a factory in which the greatest number of employees ranges from 20 to 40 years of age. The primary focus of the health program should include which of the following? 1. Reduce employee turnover. 2. Decrease employee absenteeism. 3. Improve the family relations of the employees. 4. Establish disease prevention for the employees.

4. Establish disease prevention for the employees. Strategy: Think about each answer. (1.) most employees within this age range do not leave jobs for health reasons (2.) increasing health status could decrease the percentage of absenteeism because employees generally miss work because of illness; would be a potential outcome, but is not be the primary focus of a long-term health program (3.) divorce rates are high in this age group, but not significant to health needs of employees within this age range (4.) CORRECT— although there isn't much absenteeism in this age group because of diseases, starting a prevention program at this age will pay off when the employees are older and illness is a reason for absenteeism; prevention should be the primary focus of a long-term health program

The psychiatric nurse-leader instructs the LPN/LVN to encourage a client with depression to join an activity. Which approach by the LPN/LVN is best? 1. Offer several appealing choices to the client. 2. Tell the client it is part of the health care provider's orders. 3. Describe the activity in detail to the client. 4. Invite the client to join in the activity.

4. Invite the client to join in the activity. Strategy: Think about the outcome of each answer. Is it desired? (1) limit choices, because client feels too inadequate to make choices (2) depressed client fears rejection; would want client to voluntarily join the activities rather than soliciting participation via coercion; therapy is generally designed to help client regain autonomy (3) avoid long explanations because of client's decreased attentiveness and poor concentration (4) CORRECT—good example of how a nurse might lead a client into an activity by telling the client that you would like him/her to join in; it's important to demonstrate caring and acceptance

The LPN/LVN knows that the medication is absorbed BEST by a client with a major burn by way of which of the following routes? 1. Intramuscularly. 2. Orally. 3. Intravenously. 4. Topically.

Intravenously. Strategy: "BEST" indicates discrimination may be required to answer the question. (1) fluid shift during emergent post-burn phase causes limited absorption from subcutaneous and intramuscular spaces (2) oral route not an option because client likely to be in shock or physical resources need to be routed to the burn rather than to GI tract for absorption and metabolism of drugs (3) CORRECT—fluid shift during emergent post-burn phase causes limited absorption from subcutaneous and intramuscular spaces; administer medication before painful procedures; keep environment warm to prevent shivering (4) because peripheral blood vessels have been destroyed, absorption is poor; inappropriate if goal is for drug to have systemic effect; most drugs used to promote healing of burn wounds are topical; localized effect is desired

f a client has an absence seizure, the LPN/LVN should take which action? 1. Place the client on complete bedrest. 2. Instruct the family to pad the side rails of the client's bed. 3. Observe for autonomic, purposeless motions with intense emotional experiences. 4. Monitor the client for brief interruptions of consciousness.

4. Monitor the client for brief interruptions of consciousness. Strategy: Determine the outcome of each answer. Is it desired? (1.) absence seizure is a brief period of loss of consciousness; client returns to baseline immediately after seizure; no reason to put on bedrest (2.) because there no movement of head or limbs, padded side rails not needed (3.) not common in absence seizures; in a simple partial seizure, client may have unilateral movement of an extremity, may experience unusual sensations, or may have autonomic symptoms such as a change in heart rate, skin flushing, and epigastric discomfort (4.) CORRECT— absence seizures are characterized by a momentary episode of loss of consciousness; client may have a blank stare for a few seconds, or may stop talking in the middle of a sentence; after the seizure the client is often unaware of having lost consciousness

The LPN/LVN provides care for a client after surgery. The LPN/LVN notes that the client last voided before surgery 10 hours ago. Which action does the LPN/LVN take first? 1. Insert a catheter into the bladder. 2. Encourage client to take sips of water. 3. Inform the nursing supervisor right away. 4. Palpate for bladder distention.

4. Palpate for bladder distention. Strategy: "First" indicates priority. 1) assess before implementing 2) assess the status of the bladder 3) perform assessment of client before contacting the nursing supervisor 4) CORRECT — primary focus is kidney function and return of bladder function; best source is to examine the bladder; if the kidney is functioning, urine will be in the bladder; if client has problem with voiding, bladder will be distended

The LPN/LVN assists in the dietary teaching for a client diagnosed with Graves' disease. The LPN/LVN determines that further teaching is required when the client selects which of the following foods? 1. Brook trout. 2. Apples. 3. Milk. 4. Tea.

4. Tea. Strategy: "Further teaching is required" indicates incorrect information. (1) is acceptable for client's dietary intake; needs a protein source (2) fresh fruit is an acceptable source of natural glucose (3) acceptable for diet; needs foods high in calcium; hyperthyroidism causes osteoporosis (4) CORRECT—tea is a stimulant; since Graves' disease is hyperthyroidism, which results in an excessive basal metabolic rate, do not give the client a food or fluid that would further increase the metabolic rate

A person who has had sexual contact with a client with hepatitis B is given hepatitis B immune globulin (HBIG). The LPN/LVN explains to the sexual contact that the purpose of B immune globulin (HBIG) includes which of the following? 1. Prevents other sexually transmitted diseases. 2. Stimulates the immune system to develop antibodies to hepatitis B. 3. Prevents the development of hepatitis B. 4. Temporarily increases the contact's resistance to hepatitis.

4. Temporarily increases the contact's resistance to hepatitis. Strategy: Think about each answer. (1) not action of HBIG (2) describes active immunity, which is obtained through the hepatitis B vaccine (3) no guarantee that contact won't develop hepatitis B (4) CORRECT—an injection of pooled human gamma globulin is an example of passive immunity

The nursing team consists of an RN, one LPN/LVN and two nursing assistants. The LPN/LVN should question which of the following client assignments? 1. The RN assigns the LPN/LVN to care for a client in Buck's traction. 2. The RN assigns the LPN/LVN to administer digoxin (Lanoxin) and furosemide (Lasix) via an NG tube. 3. The RN assigns the LPN/LVN to care for a client 48 hours after a hip replacement. 4. The RN assigns the LPN/LVN to care for a client 12 hours after a laminectomy with spinal fusion who is having difficulty voiding.

4. The RN assigns the LPN/LVN to care for a client 12 hours after a laminectomy with spinal fusion who is having difficulty voiding. Strategy: LPN/LVN cares for stable clients with expected outcomes. (1.) appropriate client for the LPN/LVN; stable client with expected outcome (2.) appropriate assignment for the LPN (3.) appropriate assignment for the LPN (4.) CORRECT— unstable patient, requires skills of RN

The LPN/LVN works with a middle-aged client diagnosed with hypertension. Which of the following behaviors, if observed by the LPN/LVN, indicates that the client is at the appropriate developmental stage? 1. The client has a hair transplant and frequently visits topless bars. 2. The client attempts to continue parenting his children. 3. The client spends increased time with same-sex friends. 4. The client writes a book about how to perform certain professional tasks. View Explanation

4. The client writes a book about how to perform certain professional tasks. Strategy: Think about each answer. (1.) illustrates unresolved issues associated with early adulthood (2.) letting go of children is the common task for this age group (3.) associated more with adolescence and early adulthood (4.) CORRECT— primary focus of this age group is to leave a legacy for generations that follow

The LPN/LVN cares for a client admitted to the unit with a diagnosis of acute myocardial infarction. The LPN/LVN identifies this client is attached to a cardiac monitor for which reason? 1. To monitor client's condition closely without being disturbed during sleep. 2. To prevent another, more serious heart attack from occurring. 3. To verify diagnosis of acute myocardial infarction. 4. To detect any life-threatening changes in the heart rhythm.

4. To detect any life-threatening changes in the heart rhythm. Strategy: Think about each answer. (1) does promote rest by providing assessment data by way of mechanical assessment; rest is important but is not the most relevant rationale for monitoring the client's cardiac status; early detection is the key to MI recovery (2) monitoring can identify dysrhythmias but can't prevent another MI; could detect problems early, resulting in management to prevent further damage or alteration (3) symptoms of MI include chest pain, dyspnea, nausea, vomiting, gastric discomfort, apprehension, acute pulmonary edema, or shock; change in ECG pattern can indicate whether or not MI has occurred, but does not confirm when the damage/alteration occurred; the MOST definitive diagnostic tool includes elevated CK levels or other cardiac enzymes (4) CORRECT—cardiac monitor is a continuous assessment tool that reveals the client's heart rhythm and electrical patterns; immediately provides feedback regarding any abnormalities such as PVC or ventricular fibrillation

A 2-year-old child is brought to the clinic for extensive facial burns. The child's mother states that the burns resulted from the child's running into her lit cigarette. The child is holding onto her mother's skirt and doesn't want to let go to be examined. The BEST reason for the LPN/LVN to suspect this mother is abusing her child includes which of the following? 1. The child's injury is on the face. 2. The mother is upset about the accident. 3. The child is clinging to her mother, refusing to cooperate with the nurse. 4. There is little correlation between the extent of the child's burns and the history of how the child was burned.

4.There is little correlation between the extent of the child's burns and the history of how the child was burned. Strategy: Think about each answer. (1) location of injury not as important as incompatibility between the history and presenting injury (2) other indications of abuse include conflicting stories about accident or injury, inappropriate response of caregiver such as exaggerated or absent emotional response, refusal to sign for additional tests or necessary treatment (3) warning sign of abuse includes little or no response from the child; excessive or lack of separation anxiety, indiscriminate friendliness to strangers (4) CORRECT—most important criterion is incompatibility between the history and presenting injury

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.

Auscultates the client's bowel sounds. Strategy: "First" indicates priority. 1) more appropriate if client experiences abdominal pain related to excessive flatus 2) appendectomy, if appendix not ruptured, normally does not result in severe pain; especially not 24 hours postop; pain only along with sympathetic response would be the expected clinical picture 3) CORRECT — peritonitis can be caused by ruptured appendix; signs and symptoms of peritonitis include severe abdominal pain, abdominal rigidity, decreased bowel sounds, nausea and vomiting, increased temperature, shock, paralytic ileus; monitor vital signs, administer antibiotics and IVs, NG tube to suction, NPO, surgery to correct cause 4) not likely to have odor and drainage the day after surgery; if signs and symptoms of peritonitis, impaired bowel sounds are likely; paralytic ileus is likely and life-threatening

The LPN/LVN reinforces teaching to the client diagnosed with a sprained ankle about how to apply a cold application to the ankle. The LPN/LVN includes which instructions? Select all that apply. 1. "Fill a large plastic bag completely full of ice." 2. "Tightly secure the ice bag to your ankle with an elastic wrap." 3. "Apply the ice: 20 to 30 minutes on, 15 minutes off for the first 72 hours." 4. "Place a dry cloth over the ice bag." 5. "Observe the area for blanching." 6. "Discontinue using the ice bag if you feel a burning sensation or numbness."

Determine the outcome of each answer. Is it desired? 1) amount of ice should not be bigger in size than the ankle; large amounts of ice can result in compression of the blood vessels and tissue damage 2) do not apply tightly to the ankle 3) CORRECT— decreases swelling and inflammation; do not leave on too long, will cause injury to tissues 4) dry cloth should be placed between ice pack and skin to prevent tissue damage 5) CORRECT— do not allow the skin to become too cold 6) CORRECT— indicates possible skin damage

The LPN/LVN assists in the dietary teaching for a client diagnosed with a myocardial infarction. The LPN/LVN determines teaching is effective if the client selects which of the following menus? 1. Ham and cheese sandwich, milk, fresh apple. 2. Sliced turkey, green beans, fresh pear. 3. Broiled fish, creamed spinach, custard. 4. Broiled chicken, green beans, ice cream.

Sliced turkey, green beans, fresh pear. Strategy: "Teaching is effective" indicates correct information. (1) client should avoid saturated fats and foods high in cholesterol; avoid intake of salty foods; diet should be rich in fruits, vegetables, grains, and fish, as well as high-fiber; ham is salty, and cheese is high in fat (2) CORRECT—sliced turkey, green beans, and pear are all low in cholesterol and low in salt; other meals are high in cholesterol and salt (3) broiled fish is good, but creamed spinach is high in fat, as is custard (made with milk and eggs) (4) boiled chicken and green beans are acceptable foods; ice cream high in fat and high in sugar

The LPN/LVN admits a new client to the long-term care facility. The LPN/LVN assesses the client's nutritional status. Which of the following observations by the LPN/LVN indicates that the client is adequately nourished? Select all that apply: 1. The client's conjunctiva is pale. 2. The client is 5 feet, 2 inches tall and weighs 125 pounds. 3. The client has spoon-shaped nails. 4. The client's hair is shiny and lustrous. 5. The client skin is rough, dry, and scaly. 6. The client's gums are pink in color.

Think about each answer. (1.) indicates anemia; if client is well nourished, eyes should be clear, bright, and shiny with pink conjunctiva (2.) CORRECT — weight should be normal for body build and age (3.) indicates iron deficiency anemia, malnutrition (4.) CORRECT — if client is malnourished, hair may be stringy, dull, dry, and thin (5.) skin should be smooth and slightly moist (6.) CORRECT— if client is poorly nourished, gums will be spongy and will bleed easily

The LPN/LVN implements the prenatal nursing care plan designed for a pregnant client. While instructing the client in the prenatal clinic about nutrition during pregnancy, the LPN/LVN instructs the client to add certain food combinations to her normal daily diet. The LPN/LVN determines that which of the following foods BEST reflects the additional nutrients required during pregnancy? 1. Two eggs and 8 oz of milk. 2. A 2-oz steak and 10 oz of beer. 3. A lettuce-and-tomato salad and 12 oz of orange juice. 4. One bag of potato chips and 16 oz of cola.

Two eggs and 8 oz of milk.