LVN Fundamentals 2
A client is scheduled to receive conscious sedation during a colonoscopy. The client asks the nurse, "How will they 'knock me out' for this procedure?" Which answer by the nurse correctly describes the route of administration for conscious sedation? 1. "You will receive the anesthesia through a face mask." 2. "You will receive medication through an intravenous catheter." 3. "We will give you an oral medication about one hour before the procedure." 4. "The nurse anesthetist will inject the medication into the epidural space of your spine."
Answer: 2. "You will receive medication through an intravenous catheter." Reason: Conscious sedation is administered by direct intravenous (IV) injection (IV push) to dull or reduce the intensity of pain or awareness of pain during a procedure without loss of defensive reflexes. General anesthesia usually is administered via inhalation of the vapor of a volatile liquid or an anesthetic gas via a mask or endotracheal tube; as a result, the client is unconscious, unaware, and anesthetized. An epidural block, a type of regional anesthesia, involves the injection of a local anesthetic into the epidural (extradural) space; it works by binding to nerve roots as they enter and exit the spinal cord. Epidural blocks are not used for moderate sedation. The oral route of drug administration is commonly used for pediatric clients, not adults.
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcers? 1. Stage I 2. Stage II 3. Stage III 4. Stage IV
Answer: 3. Stage III Reason: A pressure ulcer that is full thickness with necrosis and ulceration into the subcutaneous tissue and down to, but not through, the underlying fascia is characteristic of a stage III pressure ulcer. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage IV pressure ulcer involves full thickness skin loss with extensive damage and tissue necrosis to muscles, support tissues, and bone; undermining and sinus tracts may also be present.
A nurse anticipates that a hospitalized client will be transferred to a nursing home. When should the nurse begin preparing the client for the transfer? 1. At the time of admission 2. After a relative gives permission 3. When the client talks about future plans 4. As soon as the client's transfer has been approved
Answer: 1. At the time of admission Reason: Preparation of clients for discharge to their own home or to a nursing home should begin on the day of admission. The client gives permission for transfer to a nursing home. Intervention includes talking to the family members, including them in plans, and helping them understand the importance of early preparation. The client may never talk about future plans. Waiting until the client's transfer has been approved will make the adjustment more difficult than if the client had adequate preparation time.
A nurse is explaining the nursing process to a nursing assistant. Which step of the nursing process should include interpretation of data collected about the client? 1. Evaluation 2. Data Collection 3. Nursing interventions 4. Proposed nursing care
Answer: 1. Evaluation Reason: An actual or potential client health problem is based on the analysis and interpretation of the data previously collected during the assessment phase of the nursing process. Gathering data is included in the client's assessment. Nursing interventions are based on the earlier steps of the nursing process. The plan of care includes nursing actions to meet client needs. The needs first must be identified before nursing actions are planned.
The nurse recognizes that which are important components of a neurovascular assessment? (Select all that apply.) 1. Orientation 2. Capillary refill 3. Pupillary response 4. Respiratory rate 5. Pulse and skin temperature 6. Movement and sensation
Answer: 1. Orientation 4. Respiratory Rate 5. Pulse and skin temperature Reason: A neurovascular assessment involves evaluating of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluating of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurological assessment.
A nurse is assisting a client to transfer from the bed to a chair. What should the nurse do to widen the client's base of support during the transfer? 1. Spread the client's feet away from each other. 2. Move the client on the count of three. 3. Instruct the client to flex the muscles of the internal girdle. 4. Stand close to the client when assisting with the move.
Answer: 1. Spread the client's feet away from each other Reason: Spreading the feet apart widens the base of support. A wide base of support lowers the center of gravity, thereby increasing stability. Counting to three does not widen the base of support. Counting to three ensures a coordinated effort on behalf of the client and nurse to affect the move, which may alleviate some of the burden borne by the nurse. Flexing the muscles of the internal girdle (contracting the gluteal muscles in the buttocks downward and the abdominal muscles upward) stabilizes the pelvis and protects the abdominal viscera when lifting, pulling, reaching, or stooping, but it does not widen the base of support. Working close to the client is not based on the principle of widening the base of support. This action brings the center of gravity close to the client being moved, permitting the muscles of the nurse's legs and arms to carry the burden of the transfer rather than the muscles of the back.
A client admitted to the hospital with a diagnosis of malabsorption syndrome exhibits signs of tetany. The nurse concludes that the tetany was precipitated by the inadequate absorption of which electrolyte? 1. Sodium 2. Calcium 3. Potassium 4. Phosphorus
Answer: 2. Calcium Reason: The muscle contraction-relaxation cycle requires an adequate serum calcium-phosphorus ratio; the reduction of the ionized serum calcium level associated with malabsorption syndrome causes tetany (spastic muscle spasms). Sodium is the major extracellular cation. Sodium's major route of excretion is the kidneys, under the control of aldosterone. Although it plays a part in neuromuscular transmission, potassium is not related to the development of tetany. Potassium is the major intracellular cation. Potassium is part of the sodium-potassium pump and helps to balance the response of nerves to stimulation. Potassium is not related to the development of tetany. Although phosphorus is closely related to calcium because they exist in a specific ratio, phosphorus is not related to the development of tetany.
Which nursing interventions require a nurse to wear gloves? (Select all that apply.) 1 . Giving a back rub. 2. Cleaning a newborn immediately after delivery. 3. Emptying a portable wound drainage system. 4. Interviewing a client in the emergency department. 5. Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive
Answer: 2. Cleaning a newborn immediately after delivery 3. Emptying a portable wound drainage system Reason: Personal protective equipment (PPE) should be used because the newborn is covered with amniotic fluid and maternal blood. PPE should be used because the nurse may be exposed to blood and fluid that are contained in the portable wound drainage system. PPE is not required for a back rub; there is no indication that the nurse is in contact with body secretions. PPE is not necessary when conducting an interview because it is unlikely that the nurse will come in contact with the client's body fluids. PPE is not necessary when obtaining the blood pressure of a client, even if the client is HIV positive.
A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client? 1. Arrangements will be made by the client and the client's family. 2. The plan is formulated and implemented early in the client's care. 3. The rehabilitation is minimal and short term because the client will return to former activities. 4. Arrangements will be made for long-term care because the client is no longer capable of self-care
Answer: 2. The plan is formulated and implemented early in the client's care. Reason: To promote optimism and facilitate smooth functioning, rehabilitation planning should begin on admission to the hospital. The client and family often are unaware of the options available in the health care system; the nurse should be available to provide the necessary information and support. Rehabilitation helps a client adjust to a new lifestyle that must compensate for the paralysis. The goal of rehabilitation is to foster independence wherever the client may live after discharge.
What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental task associated with aging? 1. Achievement of a personal philosophy 2. Adaptation to the children leaving home 3. Attainment of a sense of worth as a person 4. Adjustment to life in an assisted-living facility
Answer: 3. Attainment of a sense of worth as a person Reason: Developing and participating in meaningful activities and satisfaction with past accomplishments increase feelings of self-worth. Achievement of a personal philosophy is a task of early adulthood. Adaptation to the children leaving home is a task of middle adulthood. Adjustment to life in an assisted-living facility is not a developmental task of older adults; not all older adults live in assisted-living facilities.
A nurse discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must self-help groups such as AA meet to be successful? 1. Trust 2. Growth 3. Belonging 4. Independence
Answer: 3. Belonging Reason: Self-help groups are successful because they support a basic human need for acceptance. A feeling of comfort and safety and a sense of belonging may be achieved in a nonjudgmental, supportive, sharing experience with others. AA meets dependency needs rather than focusing on independence, trust, and growth.
The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: 1. Force urine to back up into the kidneys. 2. Suppress production of urine. 3. Cause the device to pull away from the skin. 4. Tear the ileal conduit.
Answer: 3. Cause the device to pull away from the skin Reason: If the device becomes full and is not emptied, it may pull away from the skin and leak urine. Urine in contact with unprotected skin will irritate and cause skin breakdown. A full urine collection bag will not cause urine to back up into the kidneys, suppress the production of urine , or tear the ileal conduit
A nurse is transcribing a practitioner's orders for a group of clients. Which order should the nurse clarify with the practitioner? 1. Discharge in am 2. Blood glucose monitoring ac and bedtime 3. Erythropoietin (Procrit) 6000 units subcutaneously TIW 4. Dalteparin (Fragmin) 5000 international units Sub-Q BID
Answer: 3. Erythropoietin (Procrit) 6000 units subcutaneously TIW Reason: "TIW", indicating three times a week is an unacceptable abbreviation . It may be mistaken for "three times a day" or "twice weekly." The abbreviation "AM" for in the morning is an acceptable abbreviation. The word "discharge" must be completely spelled out instead of just "D/C" because this may be confused with "discontinue." The use of "ac" (before meals) is an acceptable abbreviation. Bedtime must be completely spelled out instead of just "hs" because "hs" may be confused with "half strength" or "every hour." The abbreviation "Sub-Q", indicating the subcutaneous route is an acceptable abbreviation. "BID," indicating twice a day, is an acceptable abbreviation. "International units" must be completely spelled out instead of just "IU" because it may be mistaken as a four.
A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: 1. A loss of skin elasticity and a decrease in libido 2. Impaired fat digestion and increased salivary secretions 3. Increased blood pressure and decreased hormone production 4. An increase in body warmth and some swallowing difficulties
Answer: 3. Increased blood pressure and decreased hormone production Reason: With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures; hormone production decreases after menopause. There may or may not be changes in libido; there is a loss of skin elasticity. Salivary secretions decrease, not increase, causing more difficulty with swallowing; there is some impairment of fat digestion. There may be a decrease in subcutaneous fat and decreasing body warmth; some swallowing difficulties occur because of decreased oral secretions.
Which age-related change should the nurse consider when formulating a plan of care for an older adult? (Select all that apply.) 1 . Difficulty in swallowing 2 . Increased sensitivity to heat 3 . Increased sensitivity to glare 4 . Diminished sensation of pain 5 . Heightened response to stimuli
Answer: 3. Increased sesitivityt to glare 4. Diminished sensation of pain Reason: Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare . Diminished sensation of pain may make an older individual unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older individuals. Older individuals tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in the older individual.
The nurse is caring for a client who is on a low carbohydrate diet. With this diet, there is decreased glucose available for energy, and fat is metabolized for energy resulting in an increased production of which substance in the urine? 1. Protein 2. Glucose 3. Ketones 4. Uric acid
Answer: 3. Ketones Reason: As a result of fat metabolism, ketone bodies are formed and the kidneys attempt to decrease the excess by filtration and excretion. Excessive ketones in the blood can cause metabolic acidosis. A low carbohydrate diet does not cause increased protein, glucose, or uric acid in the urine.
A nurse is caring for a client who has a Hemovac portable wound suction device after abdominal surgery. What is the reason why the nurse empties the device when it is half full? 1. Emptying the unit is safer when it is half full. 2. Accurate measurement of drainage is facilitated. 3. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage. 4. Fluid collecting in the unit exerts positive pressure, forcing drainage back up the tubing and into the wound.
Answer: 3. Negative pressure in the unit lessens as fluid accumulates, interfering with further drainage Reason: As drainage collects and occupies space, the original level of negative pressure decreases; the less the negative pressure, the less effective the drainage. A portable wound suction device is easy and safe to empty regardless of the amount of drainage in the unit. Drainage can be measured accurately by the calibrations on the unit or in a calibrated container after emptying. A one-way valve between the tubing and the collection chamber prevents drainage from entering the tubing and causing trauma to the wound.
A client with Addison's disease is receiving cortisone therapy. The nurse expects what clinical indicators if the client abruptly stops the medication? (Select all that apply.) 1 . Diplopia 2 . Dysphagia 3. Tachypnea 4. Bradycardia 5. Hypotension
Answer: 3. Tachypnea 5. Hypotension Reason: Tachypnea occurs with Addisonian crisis because of inadequate circulating glucocorticoids and mineralocorticoids. Inadequate circulating glucocorticoids and mineralocorticoids cause hypotension, pallor, weakness, tachycardia, and tachypnea. Double vision does not occur with Addisonian crisis. Difficulty swallowing does not occur with Addisonian crisis. Tachycardia, not bradycardia, occurs with Addisonian crisis.
A client has been instructed to stop smoking. The nurse discovers a pack of cigarettes in the client's bathrobe. What is the nurse's initial action? 1. Notify the health care provider. 2. Report this to the nurse manager. 3. Tell the client that the cigarettes were found. 4. Discard the cigarettes without commenting to the client
Answer: 3. Tell the client that the cigarettes were found Reason: Honest nurse-client relationships should be maintained so that trust can develop. Although other health care team members may need to be informed eventually, the initial action should involve only the nurse and client. Discarding the cigarettes without commenting to the client does not promote trust or communication between the client and nurse.
A nurse reinforces teaching a client about Coumadin (warfarin) and concludes that the teaching is effective when the client states, "I must not drink: 1. apple juice. 2. grape juice. 3. orange juice. 4. cranberry juice
Answer: 4. Cranberry juice Reason: Antioxidants in cranberry juice may inhibit the mechanism that metabolizes Coumadin, causing elevations in the international normalized ratio (INR), resulting in hemorrhage. Apple juice, grape juice, and orange juice are fine to drink.
A postoperative client says to the nurse, "My neighbor—I mean the person in the next room—sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? 1. Tell the neighboring client to stop singing. 2. Close the doors to both clients' rooms at night. 3. Give the complaining client the prescribed as needed sedative. 4. Move the neighboring client to a room at the end of the hall.
Answer: 4. Move the neighboring client to a room at the end of the hall. Reason: Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because they need to be monitored. The use of a sedative should not be the initial intervention.
An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse identifies an ocular problem common to persons at this client's developmental level, which is: 1. Tropia 2 .Myopia 3. Hyperopia 4. Presbyopia
Answer: 4. Presbyopia Reason: Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.
A client is scheduled for a transurethral resection of the prostate (TURP). Which statement made by the client most indicates the need for further preoperative teaching? 1. "My urine will be red after surgery." 2. "I will have a catheter after surgery." 3. "My incision will probably be painful." 4. "I will need to drink a lot after surgery."
Answer: 3. "My incision will probably be painful" Reason: The TURP procedure is performed by insertion of a scope device into the urethra to reach the prostate from within the urinary tract. No incision is made to reach the prostate, therefore the client statement about an incision being painful after surgery warrants further evaluating and teaching by the nurse. The client is demonstrating correct knowledge about the TURP procedure by stating that after surgery his urine will be red, he will have a catheter, and he will need to increase fluid intake.
The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention? 1. Upright at 90 degrees 2. Supine position 3. Raised to 45 degrees 4. Raised to 10 degrees
Answer: 3. Raised to 45 degrees Reason: Jugular vein pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation. This procedure is most accurate when the head of the bed is elevated between 30 and 45 degrees. The internal and external jugular veins should be inspected while the client is gradually elevated from a supine position to an upright 30-45 degrees. Jugular vein distention cannot accurately be assessed if the client is supine, at 90 degrees or 10 degrees.
