LPN 240 - Final Exam

A client is being discharged after application of a plaster leg cast. The nurse determines that the client understands proper care of the cast if the client makes which statement?

"I need to avoid getting the cast wet."

A client has received instructions on self-management of peritoneal dialysis. The nurse determines that the client needs further teaching if the client makes which statement?

"I will use a strong adhesive tape to anchor the catheter dressing."

The nurse is collecting data on a client with hyperparathyroidism. Which question would elicit accurate information about this condition from the client?

"Are you experiencing pain in your joints?"

The nurse is collecting data on a client with myasthenia gravis. The nurse determines that the client may be developing myasthenic crisis if the client makes which statement?

"I can't swallow very well today."

The nurse is preparing to care for a client who will be arriving from the recovery room after an above-the-knee amputation. The nurse ensures that which priority item is available for emergency use?

Surgical tourniquet

The nurse is monitoring a client for the early signs and symptoms of dumping syndrome. Which indicates this occurrence?

Sweating and pallor

The nurse is giving the client with a left leg cast crutch-walking instructions using the three-point gait. The client is allowed to touch down the affected leg. How should the nurse teach the client to use the crutches?

Crutches and the left leg, then advance the right leg

A client is admitted with an arterial ischemic leg ulcer. The nurse expects to note that this ulcer has which typical characteristic?

Deep and painful

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is reinforcing instructions to the client regarding the program. Which instruction should the nurse include?

Take a blood glucose test before exercising.

The clinic nurse is teaching a client who has just been diagnosed with osteoporosis about nutritional therapy. Which comment by the client indicates a need for further teaching?

"I'm glad I can still drink as much coffee as I want."

The nurse is collecting data on a client with a diagnosis of angina pectoris who takes nitroglycerin for chest pain. During the admission, the client reports chest pain. The nurse immediately asks the client which question?

"Where is the pain located?"

The nurse is caring for a newly admitted client with pneumonia. The primary health care provider has prescribed a sputum specimen for culture and sensitivity. The nurse should perform the actions concerning the sputum collection in which priority order? Arrange the actions in the order that they should be performed.

-Obtain and label a sterile container. -Have the client brush teeth and rinse mouth with water. -Have the client take several deep breaths before coughing. -Have the client expectorate sputum (not saliva) into sterile container. -Send the specimen immediately to the laboratory. -Administer the prescribed antibiotics.

The nurse is reinforcing instructions to a client and his family about alcohol abuse and chronic cirrhosis. The nurse determines to include which essential elements in the discharge teaching guide?

2. Avoid potentially hepatotoxic over-the-counter drugs. 3. Teach symptoms of complications and when to seek prompt medical attention. 4. Explain that cirrhosis of the liver is a chronic illness and the importance of continuous health care. 5. Avoid spicy and rough foods and activities that increase portal pressure such as straining at stool, coughing, sneezing and vomiting

An adult client trapped in a burning house suffered burns to the back of the head, the upper half of the posterior trunk, and the back of both arms. Using the rule of nines, the nurse determines the extent of the burn injury to be which percentage?

22.5 %

The nurse determines that which client is at greatest risk for development of acute respiratory distress syndrome (ARDS)?

A client with pancreatitis and gram-negative sepsis

The nurse is caring for a client with a cerebral aneurysm who is on aneurysm precautions and is monitoring the client for signs of aneurysm rupture. The nurse understands that which is an early sign of rupture?

A decline in the level of consciousness

A client with myasthenia gravis becomes increasingly weaker. The primary health care provider injects a dose of edrophonium to determine whether the client is experiencing a myasthenic crisis or a cholinergic crisis. The nurse expects that the client will have which reaction if the client is in cholinergic crisis?

A temporary worsening of the condition

The nurse is caring for the client with epididymitis. Which treatment modalities should be implemented?

Bed rest, Sitz bath, Antibotics, Scrotal elevation

The nurse is caring for a client who has developed compartment syndrome from a severely fractured arm. The client asks the nurse how this can happen. How should the nurse explain compartment syndrome?

Bleeding and swelling cause increased pressure in an area that cannot expand.

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response?

Disconnect the suction source from the catheter.

A primary health care provider places a Miller-Abbott tube in a client who has a diagnosed bowel obstruction. Six hours later, the nurse measures the length of the tube outside of the nares and notes that the tube has advanced 6 cm since it was first placed. Based on this finding, which action should the nurse take next?

Document the finding in the client's record.

The nurse is admitting a client with a possible diagnosis of chronic bronchitis. The nurse collects data from the client and notes that which signs/symptoms support this diagnosis?

Early onset cough, Purulent mucous production, Mild episodes of dyspnea

The nurse is caring for a client with circumferential burns of both legs. Which leg position is appropriate for this type of a burn?

Elevation above the level of the heart

The nurse is planning care for a client who displays confusion secondary to a neurological problem. Which approach by the nurse would be least helpful in assisting this client?

Encouraging multiple visitors at one time

A client is at risk for complications of heart failure. Which is the nurse's priority for early detection of the most likely cause of complications with this client?

Evaluating total body fluid

The nurse is trying to help the family of an unconscious client cope with the situation. Which intervention should the nurse plan to incorporate into the care routine for the client?

Explaining equipment and procedures on an ongoing basis

The nurse is reinforcing instructions to a client with diabetes mellitus about blood glucose monitoring and monitoring for signs of hypoglycemia. The nurse should teach the client that which result is a sign of hypoglycemia?

Less than 50 mg/dL

A client with myasthenia gravis is having difficulty speaking. The client's speech is dysarthric and has a nasal tone. The nurse should use which communication strategies when working with this client?

Listening attentively, Asking yes and no questions when able, Using a communication board when necessary, Repeating what the client said to verify the message

A client hospitalized with urolithiasis has a sudden significant decrease in urine output. The nurse should perform which action?

Notify the registered nurse.

The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. On the basis of this finding, which conclusion should the nurse make?

The chest tube is functioning as expected.

The nurse working in a long-term care facility is collecting data from a client experiencing chest pain. The nurse should interpret that the pain is likely a result of myocardial infarction (MI) if which observation is made by the nurse?

The pain has not been relieved by rest and nitroglycerin tablets.

The nurse reviews the nursing care plan of an older client with diabetic neuropathy of the lower extremities as a result of type 2 diabetes mellitus. The nurse plans care knowing that which problem has the highest priority for this client?

The possibility of injury as a result of decreased sensation in the legs and feet

The nurse is collecting data about how well a client diagnosed with a gastrointestinal (GI) disorder is able to absorb food. While doing this, the nurse recalls that absorption is most concerned with which bodily function?

The transfer of digested food molecules from the GI tract into the bloodstream

The nurse is evaluating the effect of dietary counseling on the client diagnosed with cholecystitis. The nurse determines the client understands the instructions given if the client states that which food item is most appropriate to include in the diet?

Turkey and lettuce sandwich

Glucagon hydrochloride injection would most likely be prescribed for which disorder?

Type 1 diabetes mellitus

A 24-year-old man seeks medical attention for complaints of claudication in the arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg. Next, the nurse should check the client's medical history for which item?

Smoking history

The nurse is gathering data on a client with a diagnosis of tuberculosis. The nurse should review the results of which diagnostic test to confirm this diagnosis?

Sputum culture

A client with a pituitary tumor will undergo transsphenoidal hypophysectomy. The nurse reinforces which information in the preoperative teaching plan for the client?

Blowing the nose following surgery is prohibited.

The nurse is caring for a client with diabetes mellitus who is scheduled to have a right below-knee amputation. The nurse assesses which factors that can put this client at risk for amputation?

Bony deformity, Limited joint mobility, Peripheral neuropathy, Peripheral vascular disease, History of skin ulcers or previous amputation

The nurse inspects the oral cavity of a client with cancer and notes white patches on the mucous membranes. The nurse interprets this occurrence as which outcome?

Characteristic of a thrush infection

The wife of a client with diabetes mellitus who takes insulin calls the nurse in a primary health care provider's office about her husband. She states that her husband is sleepy and that his skin is warm and flushed. She adds that his breathing is faster than normal and his pulse rate seems fast. Which action should the nurse tell the wife to do first?

Check his blood glucose level.

A client with a 4-day-old lumbar vertebral fracture is experiencing muscle spasms. The nurse avoids using which intervention in an effort to relieve the spasm?

Cold

A client newly diagnosed with diabetes mellitus takes NPH insulin every day at 7:00 am. The nurse has taught the client how to recognize the signs of hypoglycemia. The nurse determines that the client understands the information presented if the client watches for which signs and symptoms in the late afternoon?

Hunger; shakiness; and cool, clammy skin

The nurse stops at the scene of an automobile accident to assist a victim. The victim complains of severe leg pain, is unable to get out of the automobile, and is frightened. Which is the appropriate nursing action?

Stay with the victim.

The nurse is performing colostomy irrigation on a client. During the irrigation, the client begins to complain of abdominal cramps. The nurse should take which appropriate action?

Stop the irrigation temporarily.

The nurse should expect to note which interventions in the plan of care for a client with hypothyroidism?

3. Instruct the client about thyroid replacement therapy. 4. Encourage the client to consume fluids and high-fiber foods. 5. Inform the client that iodine preparations will be prescribed to treat the disorder. 6. Instruct the client to contact the primary health care provider (PHCP) if episodes of chest pain occur.

The nurse is caring for a client who sustained burns on the entire right leg and anterior thorax. Using the rule of nines, the extent of the burn injury should be which percentage?

36%

The nurse is caring for a client being treated for fat embolus after multiple fractures. Which data indicate to the nurse a favorable resolution of the fat embolus?

Clear chest x-ray

A client scheduled for a thyroidectomy says to the nurse, "I am so scared to get cut in my neck." Based on the client's statement, the nurse determines that the client is experiencing which problem?

Fear about impending surgery

The nurse is caring for a client following an adrenalectomy and is monitoring for signs of adrenal insufficiency. Which signs and symptoms are related to adrenal insufficiency?

Fever, Weakness, Hypotension, Mental status changes

The nurse is admitting a client with chronic kidney disease (CKD) to the nursing unit. The nurse monitors the client for which frequent cardiovascular sign that occurs in CKD?

Hypertension

The nurse is collecting data on a client admitted to the hospital with a diagnosis of myxedema. Which data collection technique would provide data necessary to support the admitting diagnosis?

Inspection of facial features

The family of an unconscious client with increased intracranial pressure is talking at the client's bedside. They are discussing the gravity of the client's condition and wondering if the client will ever recover. How should the nurse interpret the client's situation?

It is possible the client can hear the family.

A client has just returned from the cardiac catheterization laboratory. The left femoral vessel was used as the access site. After returning the client to bed and conducting an initial assessment, the nurse assisting in caring for the client expects the cardiologist to write a prescription for the client to remain on bed rest. In which position should the bed be positioned?

With the head of bed elevated no more than 30 degrees

An adult client was burned as a result of an explosion. The burn initially affected the client's entire face (the anterior half of the head) and the upper half of the anterior torso, and there were circumferential burns to the lower half of both arms. The client's clothes caught on fire and the client ran, which caused subsequent burn injuries of the posterior surface of the head and the upper half of the posterior torso. According to the rule of nines, what is the extent of this client's burn injury?

36%

Which actions are included in the nursing care of the client undergoing peritoneal dialysis?

Monitor vital signs including temperature, Weigh the client before and after dialysis, Check color and volume of dialysate solution, Maintain aseptic technique when accessing the peritoneal catheter.

The nurse is caring for a client undergoing peritoneal dialysis. The nurse checks the client and notes that the drainage from the outflow catheter is cloudy. The nurse notifies the registered nurse and plans to take which action?

Obtain a culture and sensitivity of the drainage.

The nurse is caring for a client who is developing pulmonary edema. The client exhibits respiratory distress, but the blood pressure is unchanged from the client's baseline. As an immediate action before help arrives, the nurse should perform which action?

Place the client in high-Fowler's position.

Which intervention should be contraindicated in the postprocedure care of the client following a bone biopsy of the left arm?

Place the left arm in a dependent position for 24 hours.

The nurse is caring for a client who is being treated for a pneumothorax with a closed chest tube drainage system. When repositioning the client, the chest tube disconnects. Which nursing action should be immediate?

Reattach the chest tube to the drainage system.

The nurse should reinforce instructions to a client that has had a gastrectomy about the signs and symptoms of pernicious anemia, knowing what information?

Regular monthly injections of vitamin B12 will prevent this complication.

When caring for a client diagnosed with pheochromocytoma, which signs and symptoms should the nurse note?

Severe headache, Profuse diaphoresis, Severe hypertension

The nurse reinforces teaching to a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops?

Shakiness

The nurse inspects the skin of a client who is suspected of having psoriasis. Which finding should the nurse note if this disorder is present

Silvery-white scaly lesions

A client who is paraplegic after spinal cord injury has been taught muscle-strengthening exercises for the upper body. The nurse determines that the client will derive the least muscle-strengthening benefit from which activity?

Doing active range of motion to finger joints

The nurse is preparing for a health fair about tobacco use and the development of coronary heart disease. Which information should the nurse include?

Nicotine decreases oxygen to the heart, Hypnosis may be helpful to stop smoking, Avoid exposure to environmental tobacco smoke

The nurse is providing care for a client suspected of having appendicitis. Which priority intervention should the nurse anticipate will be prescribed for this client?

No oral intake of liquids or food

A client who is performing peritoneal dialysis at home calls the clinic and reports that the outflow from the dialysis catheter seems to be decreasing in amount. The nurse appropriately asks which question first?

"Have you experienced any constipation recently?"

The nurse is collecting data from a client who is being admitted to the hospital for a diagnostic workup for primary hyperparathyroidism. The nurse understands that which client complaint would be characteristic of this disorder?

Polyuria

A primary health care provider asks the licensed practical nurse (LPN) to reinforce preprocedure instructions to a client who will undergo a barium swallow (esophagography) in a few days. The LPN should include which instruction in this discussion?

Remove all metal and jewelry before the test.