LVN 1
A client has a nursing diagnosis of Risk for injury related to adverse effects of potassium-wasting diuretics. What is a correctly written client outcome for this nursing diagnosis?
"Before discharge, the client correctly identifies three potassium-rich food sources." Reason: A client outcome must be measurable, objective, concise, realistic for the client, and attainable through nursing management. For each client outcome, the nurse should include only one client behavior, should express that behavior in terms of client expectations, and should indicate a time frame. Knowing the importance of consuming potassium-rich foods and knowing which foods are high in potassium aren't measurable. Understanding all complications isn't measurable or specific to the nursing diagnosis listed
The physician prescribes acetaminophen 650 mg by mouth every 4 hours for a client with a temperature of 102°F (38.8°C) who has a feeding tube in place. The nurse has acetaminophen solution on hand containing 160 mg/5 mL. How many milliliters of solution should the nurse administer? Record your answer using one decimal place.
20.3 ml
The nurse is teaching a client how to administer subcutaneous (subQ) insulin injections. Which injection site would be appropriate for the client to use?
Anterior aspect of the thigh Reason: SubQ injection sites, which are relatively distant from bones and major blood vessels, include the lateral aspects of the upper arm, the anterior aspects of the thigh, and the abdomen. The deltoid, rectus femoris, and vastus lateralis are I.M. injection sites
A client who suffered a head injury is in a rehabilitation center receiving 30 mL of aluminum hydroxide through a nasogastric tube every 4 hours because of his increased risk for a stress ulcer. Which potential adverse effect should the nurse monitor for with this client?
Constipation Reason: Constipation is a potential adverse effect of antacids that contain aluminum. Urine retention, nausea, and vomiting aren't adverse effects of aluminum hydroxide. Diarrhea occurs with the use of magnesium-containing antacids
For the past 24 hours, a client with dry skin and dry mucous membranes has had a urine output of 600 ml and a fluid intake of 800 ml. The client's urine is dark amber. These findings indicate which nursing diagnosis?
Deficient fluid volume Reason: Dark, concentrated urine, dry mucous membranes, and a urine output of less than 30 ml/hour (720 ml/24 hours) are symptoms of dehydration or Deficient fluid volume. Decreased urine output is related to fluid volume deficit, not Impaired urinary elimination. Nothing in the scenario suggests a nutritional problem. If a fluid volume excess were present, manifestations would most likely include signs of fluid overload such as edema
A nurse is caring for a terminally ill client. Place the following five stages of death and dying described by Elisabeth Kübler-Ross in the order in which they occur
Denial and isolation Anger Bargaining Depression Acceptance
A nurse discovers that a stat dose of potassium chloride that was prescribed by the physician was never administered. Which action should the nurse take
Notify the charge nurse so she can notify the physician of the missed dose. Reason: An error was made that needs to be addressed by notifying the charge nurse. The charge nurse should then notify the physician to determine if the medication is still appropriate for the client, and then request the medication from the pharmacy if it's still needed. The physician might order a potassium level to see if the dose is sufficient for the client. It isn't appropriate to ask the client if the medication is still needed. After the charge nurse and physician have been notified, the nurse should document the incident according to facility policy
What is the first action that a nurse should take after accidentally failing to administer an ordered medication?
Notify the prescriber, nursing supervisor, and pharmacist. Reason: When a nurse has accidentally omitted an ordered medication, she should first notify the prescriber, nursing supervisor, and pharmacist. She should then document the omission and the reason in the client's chart and, depending on facility policy, write an incident report. The nurse shouldn't give an extra dose at the next scheduled time because adverse reactions or toxicity could occur
The nurse distinguishes that which assessment data will most influence a client in crisis?
Previous coping skills Reason: Coping is the process by which a person deals with problems using cognitive and noncognitive components. Cognitive responses come from learned skills; noncognitive responses are automatic and focus on relieving discomfort. Previous coping skills are cognitive and include the thought and learning necessary to identify the source of stress in a crisis situation. Therefore, option 2 is the best answer. Age could have either a positive or negative effect during crisis, depending on previous experiences. Although sometimes useful, noncognitive measures, such as self-esteem, may prevent the person from learning more about the crisis as well as a better solution to the problem. The person involved could have correct or incorrect perception of the problem that could have either a positive or negative outcome.
The nurse is preparing to boost a client up in bed. She instructs the client to use the overbed trapeze. Which risk factor for pressure ulcer development is the nurse reducing by instructing the client to move in this manner?
Shearing forces Reason: Using a trapeze reduces shearing forces (opposing forces that cause layers of skin to move over each other, stretching and tearing capillaries and, eventually, resulting in necrosis), which increase the risk of pressure ulcer development. They can occur as clients slide down in bed or when they're pulled up in bed. To reduce shearing forces, the nurse should instruct the client to use an overbed trapeze, place a draw sheet under the client to move the client up in bed, and keep the head of the bed no higher than 30 degrees. The risks of friction, impaired circulation, and localized pressure aren't decreased with trapeze use
A nursing faculty is preparing a lecture on the foundation of nursing knowledge. Which framework for nursing education and clinical practice would faculty include in the lecture?
Theoretical and conceptual models Reason: Theoretical and conceptual models of nursing provide the foundation for all nursing knowledge. They also direct nursing practice based on the concepts of health, person, environment, and nursing. Scientific breakthroughs, technological advances, and medical practices may affect nursing but aren't frameworks for nursing education and practice
Vasodilation or vasoconstriction produced by an external cause will interfere with an accurate assessment of a client with peripheral vascular disease (PVD). Therefore, the nurse should:
keep the client warm Reason: The nurse should keep the client covered and expose only the portion of the client's body that is being assessed. The nurse should also keep the client warm by maintaining the room temperature between 68° F and 74° F (20° to 23.3° C). Extreme temperatures aren't good for clients with PVD because the valves in their arteries and veins are already insufficient and exposing them to vast changes in temperature could influence the client's response. A room temperature of 78° F may be too warm for some clients and too cool for others. Keeping the client uncovered would lead to chilling. Matching the room temperature with the client's body temperature is inappropriate
A pregnant client with vaginal bleeding asks a nurse how the fetus is doing. Which response is best?
"I'll tell you what the monitors show." Reason: The client deserves a truthful answer and the nurse should be objective without giving opinions. Relating what the monitors show is objective and truthful. Vague answers may be misleading and aren't therapeutic
A nurse is caring for a client who was admitted with an acute head injury. The client has stabilized and is ready to begin rehabilitation. When transferring the client from his bed to a chair, what should the nurse do to ensure client safety?
Lock the brakes on the bed Reason: Locking the wheels of the bed (and wheelchair, if one is used) helps to prevent the bed (and chair) from sliding away, thus preventing injuries. The side rail on the side of the bed where the nurse is standing should be lowered to facilitate the transfer. Positioning the chair alongside the bed, rather than 2 feet away, helps the client to pivot into the chair. The nurse should place shoes or slippers with nonskid soles on the client's feet to help prevent slipping during the transfer
Which aspect of drug therapy is most important when planning nursing care for an elderly client?
Noncompliance Reason: Noncompliance in older clients is so prevalent that most nurses consider it a top priority when planning nursing care. An undesired drug action is a factor that can make it harder for the client to remain compliant, but the issue of compliance is a higher priority overall. Elderly clients commonly require reduced drug dosages; however, noncompliance may cause the physician to increase dosages if the client's symptoms appear not to resolve with current dosages.
When auscultating a client's abdomen, the nurse detects high-pitched gurgles over the lower right quadrant. Based on this finding, how would the nurse describe this to the client?
Nothing abnormal Reason: High-pitched gurgles are a normal finding. Decreased bowel motility causes two or three bowel sounds per minute; increased bowel motility causes hyperactive bowel sounds. Abdominal cramping causes hyperactive, high-pitched tinkling bowel sounds and may indicate a bowel obstruction
A licensed practical nurse (LPN/LVN) is working with the RN in verifying a heparin IV infusion rate. The prescribed dose is 400 units of heparin per hour. The heparin is in a solution of 5,000 units/100 mL NS. How many milliliters per hour should the pump be set?
8 ml/hr
The nurse is caring for a 40-year-old client admitted with an acute myocardial infarction. Which behavior by the client indicates adult cognitive development?
Generates new levels of awareness Reason: Adults ages 31 to 45 generate new levels of awareness. Having perceptions based on reality and assuming responsibility for actions indicate socialization development — not cognitive development. Demonstrating maximum ability to solve problems and learning new skills occur in young adults ages 20 to 30
A client with cirrhosis is jaundiced and edematous. He's experiencing severe itching and dryness. Which intervention is best to help the client?
Use alcohol-free body lotion. Reason: Alcohol-free body lotion applied to the skin is best to help relieve dryness and is absorbed without oiliness. Mitts may help keep the client from scratching his skin open. Baby oil doesn't allow excretions through the skin and may block pores. Soap dries out the skin.
The nurse is reviewing the medication administration record (MAR) in preparation for medication administration. Which of the following orders should the nurse question?
acetaminophen 650 mg PO as needed Reason: The acetaminophen order does not have a time frame and therefore is not safe. The way the order is written can cause a client to overdose. All the other prescriptions have all the required information for accurate medication administration.
