LPN 1001 Basic Physical Care LWW (Graded A), Latest Question and Answer Solutions

Document Content and Description Below

Basic Physical Care LWW A client hospitalized with pneumonia has thick, tenacious secretions. To help liquefy these secretions, the nurse should: Correct response: • encourage increased flu... id intake. A client must undergo right thoracotomy for lung cancer. Which member of the health care team is responsible for obtaining informed consent from this client? Correct response: • Physician The nurse is aware that Standard Precautions represent the first tier of Centers for Disease Control guidelines for isolation precautions. Which is the nurse's primary responsibility when following Standard Precautions? Correct response: • Consider all body substances potentially infectious. A client suddenly loses consciousness. What should the nurse do first? Correct response: • Assess for responsiveness. The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution after the procedure, the nurse can anticipate that he'll require: Correct response: • a chest X-ray. The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's: Correct response: • foot. While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse to apply? Correct response: • Moist sterile saline gauze The nurse is caring for a dying client who's receiving comfort measures. Which intervention by the nurse is most effective in promoting comfort? Correct response: • Combing the client's hair The charge nurse is making assignments for nurses working on a medical surgical unit. Which clients could be assigned to the licensed practical nurse (LPN)? Select all that apply. Correct response: • a client in need of tracheostomy dressing • a client in need of Foley catheterization • a client on tube feeding who needs the nasogastric tube checked for patency • a diabetic client who needs reinforcement of teaching on insulin administration The nurse on a medical surgical unit receives the end-of-shift report from the outgoing nurse. Which client should the nurse see first? Correct response: • 3-day postoperative client with a temperature of 102.5 degrees Fahrenheit (39.2 C) The LVN/LPN asked the unlicensed assistive personnel to transfer a postoperative client out of bed to the chair. During the transfer, the client falls and fractures the right hip. Who should be held responsible for this injury? Correct response: • the LVN/LPN The health care provider ordered normal saline solution 1000 ml to be administered in 6 hours with a drop factor of 20 drops/ml. In whole numbers, what is the rate of infusion? Record your answer using a whole number. Correct response: • 56 A client with Alzheimer’s disease begins supplemental feedings through a gastrostomy tube to provide adequate calorie intake. What should the nurse be most concerned about with this client? Correct response: • aspiration A nurse is caring for a client who underwent a retinal detachment repair using an air bubble. The nurse is informed by the health care provider to "Keep client in prone position." Which action should the nurse take? Correct response: • Follow the prescription because this position will help keep the retinal repair intact. A nurse is caring for a client who is unconscious. In which position should the nurse place the client? Correct response: • side-lying with the head of the bed elevated The nurse is recording the intake and output for a client with the following: D5NSS 1,000 mL; urine 450 mL; emesis 125 mL; Jackson Pratt drain #1 35 mL; Jackson Pratt drain #2 32 mL; and Jackson Pratt drain #3 12 mL. How many milliliters should the nurse document as the client’s output? Record your answer using a whole number. Correct response: • 654 The nurse is preparing the room for a client diagnosed with varicella. Which sign would the nurse place on the room door? Correct response: • Airborne A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. Which finding indicates that the client is responding appropriately to TENS therapy? Correct response: • The client reports an improvement in discomfort over the painful area. A nurse is caring for a client with renal failure requiring peritoneal dialysis. The nurse does not feel comfortable performing the procedure. Which actions would be the most appropriate for the nurse to take? Select all that apply. Correct response: • Ask the supervising nurse for assistance in using the equipment. • Talk with the charge nurse about not feeling comfortable with the procedure. The nurse is collecting data on four clients that present to the community health care center. Which vital sign measurement should be brought to the attention of the health care provider immediately? Correct response: • 14-year-old's heart rate – 56 beats per minute The nurse is caring for an unconscious client who suffered a stroke 4 days ago. When providing oral hygiene for this client, the nurse must take which essential action? Correct response: • Placing the client in a side-lying position The nurse is caring for a female client who underwent surgery 8 hours ago and is unable to void. When placing an indwelling urinary catheter in this client, the nurse should first advance the catheter how far into the urethra? Correct response: • 2" (5 cm) A client is prescribed acetaminophen by mouth every 4 hours as needed for headache. Which factor in the client's medical history would cause the nurse to question this order? Correct response: • Cirrhosis During a community clinical rotation, the nursing students interview an employer that established a physical exercise area in his workplace and encourages all employees to use it. The nursing instructor asks the student to indicate the level of health promotion exemplified by the exercise area. How would the student respond? Correct response: • "This is an example of primary prevention." A client with a vascular disease is prescribed elastic stockings. Nursing care for this client includes removing elastic stockings at least once per day. Which rationale is the nurse using this intervention? Correct response: • To observe the lower extremities The nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse would: Correct response: • remove the warm compress after 20 minutes for at least 15 minutes. For the past few days, a client has been having calf pain and notices that the painful calf is larger than the other one. The right calf is red, warm, achy, and tender to touch. Which question about the pain should the nurse include in the data collection? Correct response: • "Is the pain worse when your toes are pointed toward your knee?" The operating room nurse assists with an anterior iliac crest bone marrow aspiration on a client. After the procedure, what related nursing interventions are appropriate? Select all that apply. Correct response: • place the client in the supine position • take and record vital signs • apply pressure to the puncture site for 5-10 minutes A nurse is on duty on a medical surgical unit when the fire alarm sounds. What is the nurse's priority intervention? Correct response: • close all doors to the client rooms A nurse is caring for a client on a mental health unit and receives a call asking to know if the client is admitted on that unit. What should the nurse do? Correct response: • verify the identity of the caller A nurse working in the postanesthesia care unit is caring for multiple postoperative clients . Which task chould be delegated to unlicensed assistive personnel (UAP)? Correct response: • apply sequential compression device to the client’s leg The nurse is planning care for a client who is argumentative and demanding, calling the nurse frequently. What is the nurse’s best intervention? Correct response: • include the client in the decision-making process The nurse cares for a client who is postoperative right modified mastectomy. The client has a pressure dressing on the surgical site. Which priority care intervention should the nurse provide for this client? Correct response: • encouraging coughing and deep breathing A nurse is caring for a client with type 2 diabetes. When should the nurse inform this client to take the oral antidiabetic agent glipizide? Correct response: • before breakfast A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test? Correct response: • encourage increased oral fluid intake A nurse is caring for a client with a tracheostomy. Which equipment should the nurse gather to perform tracheostomy care? Correct response: • sterile gloves and sterile saline solution The nurse is applying an elastic bandage to a client’s arm. In order to prevent circulatory impairment, which method is best? Correct response: • stretch the bandage slightly while wrapping toward the heart A client who is bleeding internally needs emergency surgery to stop the bleeding, but refuses treatment. Which are grounds for challenging a client’s right to refuse treatment? Select all that apply. Correct response: • The client is incompetent. • Compelling reasons exist to overrule the client’s wishes. The nurse is caring for multiple clients that have been determined to be at risk for falls. Which intervention(s) should the nurse institute to prevent falls? Select all that apply. Correct response: • Orient client to the nurse call system and encourage its use. • Ensure the nurse call system is within reach. • Keep hospital bed in low position. A pregnant client who comes to the prenatal clinic is diagnosed with a chlamydia infection. When providing care to the client, the nurse anticipates that the primary care provider would most likely prescribe which medication? Correct response: • azithromycin A client with a history of heart failure is at risk for fluid volume excess. Which nursing intervespeention would ensure the most accurate monitoring of the client's fluid status? Correct response: • Weighing the client at the same time each day The nurse is recording a client's complaint of painful urination. When documenting this symptom, the nurse should use which term? Correct response: • Dysuria A client is admitted with multiple pressure ulcers. When developing the client's diet plan, the nurse should include: Correct response: • ground beef patties. A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial plan of care? Correct response: • Placing the client in isolation and using airborne precautions The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed? Correct response: • Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed? Correct response: • Irrigate continuously until the solution becomes clear or all of the solution has been used. An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she states, "My dressing is very wet with drainage." Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take? Correct response: • Lift up the dressing to check the wound. A nurse notes that a client frequently coughs while eating. The licensed practical nurse (LPN) reports this finding to the registered nurse and discusses possible options to address this problem. Based on the discussion, which health team member would the LPN expect to become involved? Correct response: • speech therapist A nurse is working at a local emergency department. A nearby building explosion has occurred, and many of the victims involved are being brought to the facility. Which client would the nurse expect to be triaged first? Correct response: • a 62-year-old with tachypnea When receiving a client assignment, which assignment should the licensed practical nurse (LPN) recognize as being outside of the LPN scope of practice? Select all that apply. Correct response: • initiating a blood transfusion • completing an initial admission assessment The nurse, who is providing care for four clients, receives a report on the clients. Which report is an outcome indicator? Correct response: • pain level 3/10 one hour after administration of pain medication A nurse is preparing to administer a preoperative intramuscular (IM) injection a 9-year-old child. Which size needle should the nurse select? Correct response: • 22G, 1-inch A nurse is caring for a client with a history of falls. What is the first priority when caring for a client at risk for falls? Correct response: • keep the bed in the lowest possible position A nurse is providing oral care for a comatose client. Which priority nursing intervention should the nurse perform for this client? Correct response: • Position the head of bed low with the client turned laterally. A nurse is caring for a client who underwent stapedectomy. To prevent postoperative complications, what should the nurse instruct the client to do? Correct response: • "Sneeze with your mouth open." A client reports an inability to sleep while on the medical unit. Which intervention to promote sleep has priority? Correct response: • question the client about sleeping habits A nurse wants to use a waist restraint for a client who wanders at night. Which intervention should be considered before applying the restraint? Correct response: • the client’s reason for getting out of bed A nurse is removing an indwelling urinary catheter. Which nursing action reflects the best technique? Correct response: • document the time of removal The nurse provides care for a client admitted with a diagnosis of acute renal failure and heart failure. The client is prescribed digoxin and spironolactone. What finding indicates that the client is experiencing a complication? Correct response: • confusion The nurse is caring for a group of clients on the acute care unit. Which events require that an incident report be completed? Select all that apply. Correct response: • Client elopement for more than 4 hours. • Stage 3 or 4 pressure ulcer acquired after admission to the health care facility. • Death or injury associated with a prior history of hypoglycemia. Which data collection finding by the nurse contraindicates the application of an aquathermic heating pad? Correct response: • Active bleeding 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? Correct response: • Deficient fluid volume Which scenario requires the licensed practical nurse (LPN) to notify the registered nurse (RN) immediately? Correct response: • Apical pulse rate of 90 beats/minute with a radial pulse rate of 70 beats/minute Which client requires further data collection by the licensed practical nurse (LPN)? Correct response: • The client who's restless The nurse is completing the intake and output record for a client. The client has had the following intake and output during the shift: Intake: 4 oz (120 mL) of cranberry juice, 1/2 bowl of oatmeal, 2 slices of toast, 8 oz (240 mL) of black decaffeinated coffee, tuna fish sandwich, 1/2 cup (120 mL) of fruit-flavored gelatin, 1 cup (240 mL) of cream of mushroom soup, 6 oz (180 mL) of 1% milk, and 16 oz (480 mL) of water. Output: 1,300 mL of urine. How many milliliters should the nurse document as the client's intake? Record your answer using a whole number. Correct response: • 1380 A client in the long-term care facility sustains a fall when trying to get out of the bed. What is the priority action by the nurse? Correct response: • obtain subjective and objective data to determine injury The nurse receives a call from the laboratory with lab values. Which lab value represents the highest priority for the nurse? Correct response: • calcium, total 32 mg/dL (8 mmol/L) A nurse is providing cardiopulmonary resuscitation (CPR) to a 4-year-old. What should the nurse do? Correct response: • use the heel of one hand for sternal compressions A nurse is caring for a neonate who has been found to have developmental dysplasia of the hip (DDH). Which position is best for this neonate? Correct response: • prone position with hips abducted A nurse is administering eyedrops to a client with glaucoma. To achieve maximum absorption, where in the eye should the nurse instill the eyedrops? Correct response: • into the conjunctival sac A nurse is administering a preoperative sedative to a client who is scheduled to have surgery. After administering the preoperative sedative, what should the nurse do next? Correct response: • put the bed in the lowest position with the side rails up A client with Alzheimer’s disease begins supplemental feedings through a gastrostomy tube to provide adequate calorie intake. What should the nurse be most concerned about with this client? Correct response: • aspiration A nurse prepares to perform postural drainage on a client. How should the nurse determine the best position to facilitate clearing the lungs? Correct response: • auscultation of lung sounds An anesthesiologist prescribes atropine for a client who is scheduled to undergo cholecystectomy. The client asks the nurse why this drug is needed preoperatively. What is the best response by the nurse? Correct response: • “The drug will dry up respiratory secretions and interrupt stimulation of the vagal nerve.” A client with cirrhosis is jaundiced, edematous and experiencing severe itching with dryness. Which intervention is best to help the client? Correct response: • use alcohol-free body lotion The infection control nurse is making rounds to ensure that airborne precautions are being observed while caring for clients with tuberculosis. Which action by the staff nurse requires further education? Correct response: • The nurse dons a surgical isolation mask when entering the client’s room. A nurse is caring for a client with a history of falls. Which interventions take priority in this client’s care? Select all that apply. Correct response: • Place the call light within the client's reach. • Keep the bed in the lowest possible position. • Provide immediate response to the client’s toileting needs. The nurse finds the family member of a client in the nutrition room standing in a puddle of water holding the microwave door, shaking. What should the nurse do first? Correct response: • Unplug the microwave. A client is released from the emergency department after being treated for a sprained ankle. Which nursing action demonstrates safe practice for a client who's learning to walk with crutches? Correct response: • placing a walking belt around the client's waist A client has been diagnosed with sleep apnea and the nurse is reinforcing education regarding the use of the continuous positive airway pressure (CPAP) device for home use. What statement made by the client indicates to the nurse that further reinforcement of the information should be done? Correct response: • “I only have to use the CPAP if I am at home, but I don’t have to use it when I am traveling away from home.” The physician enters an order into the computer for a client who underwent abdominal surgery 24 hours ago. The order states: "Get client out of bed to chair twice daily." Which action should the nurse take when she transfers the client to the chair? Correct response: • Help the client sit up and dangle his legs over the side of the bed A client is prescribed acetaminophen by mouth every 4 hours as needed for headache. Which factor in the client's medical history would cause the nurse to question this order? Correct response: • Cirrhosis The nurse is caring for a client who required chest tube insertion for a pneumothorax. To assess a client for pneumothorax resolution after the procedure, the nurse can anticipate that he'll require: Correct response: • a chest X-ray. The nurse must apply an elastic bandage to a client's ankle and calf. She should apply the bandage beginning at the client's: Correct response: • foot. The nurse has just removed an I.V. catheter from a client's arm because fluid has infiltrated the arm. The physician orders warm soaks for the area. Based on the principles of heat and cold application, the nurse would: Correct response: • remove the warm compress after 20 minutes for at least 15 minutes. A female client who had pelvic surgery 2 weeks ago is readmitted to the facility with a warm, tender, reddened area on her right calf. Which of the following contributing factors would the nurse recognize as most important? Correct response: • Recent pelvic surgery Which of the following outcome criteria would be most appropriate for the client with a nursing diagnosis of Ineffective airway clearance? Correct response: • Breath sounds clear on auscultation 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? Correct response: • Shearing forces When caring for a client with a 3-cm stage II pressure ulcer on the coccyx, which action can the nurse institute independently? Correct response: • gently irrigating the wound with a normal saline solution and applying a protective dressing as necessary A child diagnosed with chickenpox is asked to stay home from school to avoid infecting other children. The caregiver of the child asks the nurse, “When is the infectious period?” What statement made by the nurse is most accurate? Correct response: • "The client is infectious 1-2 days before the rash appears and until the blisters are crusted." Which activities can the nurse delegate to the unlicensed assistive personnel (UAP) to document on the client's chart? Select all that apply. Correct response: • bed bath • ambulation • intake and output • repositioning the client A health care institution embarked on a quality improvement project to decrease the number of client falls. Which activities by the nursing staff will help the institution achieve this goal? Select all that apply. Correct response: • conduct hourly rounds • evaluate the client’s ability to use an assistive device • keep the bed in a low position The licensed practical nurse (LPN) is part of a team caring for a group of clients in a community. Which task carried out by the LPN best describes team nursing? Correct response: • providing total care to clients with other health personnel The nurse is talking to a client who suddenly begins to choke and cough forcefully while eating lunch. What is the priority action by the nurse? Correct response: • do not intervene at this time A nurse is caring for a client who underwent a retinal detachment repair using an air bubble. The nurse is informed by the health care provider to "Keep client in prone position." Which action should the nurse take? Correct response: • Follow the prescription because this position will help keep the retinal repair intact. A nurse is providing fluid replacement for a client with burns on 35% of the body that occurred 12 hours previously. The client's blood pressure is 85/60 mm Hg, pulse is 124 beats/minute, and urine output was 25 mL during the past hour. What prescription should the nurse expect to receive from the health care provider? Correct response: • increase the IV fluid infusion rate A nurse is caring for a client with lower back pain who is scheduled for myelography using a water-soluble contrast dye. After the test, the nurse should place the client in which position? Correct response: • head of the bed elevated 45 degrees A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test? Correct response: • encourage increased oral fluid intake The nurse administers sublingual nitroglycerin to a client who reports chest pain. Which client symptom should the nurse report immediately? Correct response: • irregular heart beat A nurse is caring for a client with renal failure requiring peritoneal dialysis. The nurse does not feel comfortable performing the procedure. Which actions would be the most appropriate for the nurse to take? Select all that apply. Correct response: • Ask the supervising nurse for assistance in using the equipment. • Talk with the charge nurse about not feeling comfortable with the procedure. A client with a history of heart failure is at risk for fluid volume excess. Which nursing intervention would ensure the most accurate monitoring of the client's fluid status? Correct response: • Weighing the client at the same time each day The nurse is caring for a female client who underwent surgery 8 hours ago and is unable to void. When placing an indwelling urinary catheter in this client, the nurse should first advance the catheter how far into the urethra? Correct response: • 2" (5 cm) The nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? Correct response: • By supplying a magic slate or similar device The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed? Correct response: • Irrigate continuously until the solution becomes clear or all of the solution has been used. While examining a client's leg, the nurse notes an open ulceration with visible granulation tissue in the wound. Until a wound specialist can be contacted, which type of dressings is most appropriate for the nurse to apply? Correct response: • Moist sterile saline gauze The nurse has been teaching a client about a high-protein diet. The teaching is successful if the client identifies which meal as high in protein? Correct response: • Baked beans, hamburger, and milk A nurse notes that a client frequently coughs while eating. The licensed practical nurse (LPN) reports this finding to the registered nurse and discusses possible options to address this problem. Based on the discussion, which health team member would the LPN expect to become involved? Correct response: • speech therapist The nurse is caring for a dying client who's receiving comfort measures. Which intervention by the nurse is most effective in promoting comfort? Correct response: • Combing the client's hair The nurse is providing teaching for a client with hepatitis A. Which statement by the client indicates the need to reinforce the teaching? Correct response: • “It is all right to French kiss my partner.” A disaster has been reported a few miles from an area hospital. Which of the following roles should be assigned to the LVN/LPN? Correct response: • render first aid to injured clients A client has a prescription for a low-fat diet. When reviewing the client’s food diary, which food items would the nurse suggest that client eliminate from their diet? Select all that apply. Correct response: • cream cheese • beef sausage • Milk chocolate The charge nurse is making assignments for nurses working on a medical surgical unit. Which clients could be assigned to the licensed practical nurse (LPN)? Select all that apply. Correct response: • a client in need of tracheostomy dressing • a client in need of Foley catheterization • a client on tube feeding who needs the nasogastric tube checked for patency • a diabetic client who needs reinforcement of teaching on insulin administration A nurse working in the postanesthesia care unit is caring for multiple postoperative clients . Which task chould be delegated to unlicensed assistive personnel (UAP)? Correct response: • apply sequential compression device to the client’s leg A nurse working in the emergency department (ED) is caring for several clients. The nurse determines that obtaining informed consent for treatment would be unnecessary for which client? Correct response: • the client who is bleeding profusely from a car crash The nurse cares for a client who is postoperative right modified mastectomy. The client has a pressure dressing on the surgical site. Which priority care intervention should the nurse provide for this client? Correct response: • encouraging coughing and deep breathing A client reports an inability to sleep while on the medical unit. Which intervention to promote sleep has priority? Correct response: • question the client about sleeping habits A client who is bleeding internally needs emergency surgery to stop the bleeding, but refuses treatment. Which are grounds for challenging a client’s right to refuse treatment? Select all that apply. Correct response: • The client is incompetent. • Compelling reasons exist to overrule the client’s wishes. A client is prescribed transcutaneous electrical nerve stimulation (TENS) for pain relief. Which finding indicates that the client is responding appropriately to TENS therapy? Correct response:ulcer • The client reports an improvement in discomfort over the painful area. A nurse is caring for a client who has returned from esophagogastroduodenoscopy (EGD). Prior to offering oral fluids, what is a priority action by the nurse? Correct response: • Check the gag reflex. A client is confused and continuously attempts to get out of bed. The health care provider prescribes a vest restraint. When applying the vest restraint, what should the nurse keep in mind? Correct response: • Allow room for the client to turn. Which measures should the nurse include in the plan of care to help minimize calcium loss from the bones of a hospitalized client? Correct response: • Encourage the client to walk in the hallway The nurse is caring for an unconscious client who suffered a stroke 4 days ago. When providing oral hygiene for this client, the nurse must take which essential action? Correct response: • Placing the client in a side-lying position A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial plan of care? Correct response: • Placing the client in isolation and using airborne precautions During a community clinical rotation, the nursing students interview an employer that established a physical exercise area in his workplace and encourages all employees to use it. The nursing instructor asks the student to indicate the level of health promotion exemplified by the exercise area. How would the student respond? Correct response: • "This is an example of primary prevention." The nurse must apply a wet-to-dry dressing over an ulcer on a client's left ankle. How should the nurse proceed? Correct response: • Lightly pack the moistened fine-mesh gauze dressings into all depressions and grooves of the wound. When preparing a client with a draining vertical incision for ambulation, where should the nurse apply reinforced dressings? Correct response: • At the base of the wound A client with a vascular disease is prescribed elastic stockings. Nursing care for this client includes removing elastic stockings at least once per day. Which rationale is the nurse using this intervention? Correct response: • To observe the lower extremities An obese, malnourished client has undergone abdominal surgery. While ambulating on the fourth postoperative day, she states, "My dressing is very wet with drainage." Before this activity, the dressing was dry and intact. Which is the best initial action for the nurse to take? Correct response: • Lift up the dressing to check the wound. 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? Correct response: • Deficient fluid volume A client with terminal breast cancer is being cared for by a long-time friend who's a physician. The client has identified her twin sister as the agent in her durable power of attorney. The client loses decision-making capacity, and the twin sister says to the nurse, "There will be a different physician caring for my sister now. I've dismissed her friend." In response, the nurse should: Correct response: • abide by the wishes of the sister who is the durable power of attorney agent. A nurse is working at a local emergency department. A nearby building explosion has occurred, and many of the victims involved are being brought to the facility. Which client would the nurse expect to be triaged first? Correct response: • a 62-year-old with tachypnea The health care provider ordered normal saline solution 1000 ml to be administered in 6 hours with a drop factor of 20 drops/ml. In whole numbers, what is the rate of infusion? Record your answer using a whole number. Correct response: • 56 A nurse is administering a preoperative sedative to a client who is scheduled to have surgery. After administering the preoperative sedative, what should the nurse do next? Correct response: • put the bed in the lowest position with the side rails up A nurse is caring for a client who is unconscious. In which position should the nurse place the client? Correct response: • side-lying with the head of the bed elevated The nurse is applying an elastic bandage to a client’s arm. In order to prevent circulatory impairment, which method is best? Correct response: • stretch the bandage slightly while wrapping toward the heart The nurse is recording the intake and output for a client with the following: D5NSS 1,000 mL; urine 450 mL; emesis 125 mL; Jackson Pratt drain #1 35 mL; Jackson Pratt drain #2 32 mL; and Jackson Pratt drain #3 12 mL. How many milliliters should the nurse document as the client’s output? Record your answer using a whole number. Correct response: • 654 A nurse is caring for a client who is recovering from an illness requiring prolonged bed rest. Based on the nursing documentation, which procedure would the nurse implement next? Correct response: • Perform active range-of-motion exercises of the legs. An adult client's vital signs are temperature, 98.9° F (37.2° C); heart rate, 102 beats/minute; respiratory rate, 16 breaths/minute; and blood pressure, 95/60 mm Hg. Which terminology should the nurse use to document these findings? Select all that apply. Correct response: • afebrile • tachycardic • eupenic • hypotensive To verify the placement of a nasogastric feeding tube, what action should the nurse perform? Correct response: • Obtain a chest X-ray. The nurse is collecting data on four clients that present to the community health care center. Which vital sign measurement should be brought to the attention of the health care provider immediately? Correct response: • 14-year-old's heart rate – 56 beats per minute The nurse is informed by the secretary that her client will soon be returning from the postanesthesia care unit. What should the nurse do when preparing a surgical bed? Correct response: • Leave the bed in the high position when finished The physician inserts a chest tube into a client to treat a pneumothorax. The tube is connected to water-seal drainage. The nurse can prevent chest tube air leaks by: Correct response: • checking and taping all connections. When teaching a client with peripheral vascular disease about foot care, the nurse should include which instruction? Correct response: • Avoid wearing canvas shoes. The nurse is preparing to help a client with weakness in his right leg transfer from the bed to a chair. Where should the nurse place the chair? Correct response: • Parallel to the bed on the right side A client develops a temperature of 102° F (38.9° C). The nursing instructor concludes which actions by the student nurse requires further explanation and teaching? Select all that apply. Correct response: • The student covers the client with a heavy blanket. • The student helps the client select a low-calorie diet. A nurse is preparing several clients for surgery. Which of the following laboratory result from the clients takes priority? Correct response: • international normalized ratio (INR) 3.5 A health care institution embarked on a quality improvement project to decrease the number of client falls. Which activities by the nursing staff will help the institution achieve this goal? Select all that apply. Correct response: • conduct hourly rounds • evaluate the client’s ability to use an assistive device • keep the bed in a low position A 3-year-old boy is having surgery to repair severe hypospadias. He returns from surgery with dextrose 5% in water (D5W) infusing IV at 40 mL/hour, an indwelling urinary catheter in place, and a prescription for diet as tolerated and pain medication as needed. Which action would be best for the nurse to perform in order to prevent separation of the incision? Correct response: • elevate the scrotal sac The nurse is caring for an infant choking on a small object. The infant is conscious, not making any sounds, and becoming cyanotic. What is the nurse’s first intervention? Correct response: • five chest thrusts A neonate born 2 hours ago has just arrived in the nursery. The nurse is assisting with maintaining the neonate’s temperature. Which action would be most appropriate to help prevent heat loss due to evaporation? Correct response: • drying thoroughly after the bath A client who has had spinal anesthesia is under a health care provider’s directive to lie flat postoperatively. By adhering to this request, the client can avoid which complication? Correct response: • severe headache A nurse is caring for a client with a chest tube. If the chest drainage system is inadvertently disconnected, what is the nurse’s priority action? Correct response: • place the end of the chest tube in a container of sterile saline solution A nurse has a four-client assignment in the medical step-down unit. When planning care for the clients, which client would have the following treatment goals: fluid replacement, vasopressin replacement, and correction of underlying intracranial pathology? Correct response: • the client with diabetes insipidus (DI) The nurse is teaching a client how to change an ostomy appliance via a step-by-step outline. Place the instructions in ascending chronological order. Correct response: • Wash stoma area and pat dry. • Measure the stoma site. • Add 1/16 to 1/8 inch to the size of the stoma. • Cut stoma opening into wafer. • Apply thin layer of paste around stoma. • Apply pouch. A client with facial lacerations requires wound care, I.V. antibiotics, and hospitalization for 1 week. During the assessment on the third admission day, the nurse notes scabs on the wounds. This finding corresponds to which phase of the normal wound healing? Correct response: • proliferative phase A client in a long-term care facility has become confused, trying to get out of bed without assistance and is at risk for injury due to falls. Which nursing actions comply with a least restraint policy? Select all that apply. Correct response: • placing the client in a bed with a bed alarm • providing a bed that is low to the floor • raising three side rails while the client is in bed The nurse is caring for a group of clients. Which activities by the nurse is the best example of the nurse as an interdisciplinary team member? Correct response: • recommending a physical therapy consult because of altered mobility A LPN/LVN working in a community health center is reinforcing family needs during a disaster planning drill. What should be included in the family preparedness drill? Select all that apply. Correct response: • Prepare a package of vital records. • Have extra medications and food items for dietary requirements. • Establish a place to meet in an emergency. A client is diagnosed with cellulitis of the lower leg from a spider bite. What information can the nurse reinforce to help relieve the pain and inflammation? Correct response: • Apply warm compresses to the leg. The nurse is gathering data from a client on the first day after a thoracotomy. The client has a temperature of 100°F (37.8°C); heart rate, 96 beats/minute; blood pressure, 136/86 mm Hg; and shallow respirations at 24 breaths/minute, with rhonchi at the bases, and reports incisional pain. Which nursing action has priority? Correct response: • Medicate the client for pain. An unlicensed assistive personnel (UAP) is observed leaving the room of a client in isolation. The nurse recognizes the UAP is following proper technique when he or she removes which protective equipment first? Correct response: • Gloves A client with a chest tube refuses to get out of bed because of the discomfort caused by the tube. Which intervention should the nurse perform to increase this client’s adherence with activity and deep breathing? Correct response: • Administer analgesic medication as prescribed. A client arrives in the emergency department with a nosebleed. What is the first action by the nurse? inCorrect response: • pinch the nares together at the bridge of the nose An adult male client with Parkinson’s disease is frequently incontinent of urine. Which intervention by the nurse is appropriate? Correct response: • apply a condom catheter The nurse is caring for a client with human immunodeficiency viirus (HIV) and reinforcing education regarding disease prevention. What is the importance of disease prevention for this client? Correct response: • The client's personal behavior has a direct link to the maintenance of health. A certified nursing assistant (CNA) is caring for a client with Clostridium difficile diarrhea and asks the nurse, "How can I keep from catching this from the client?" The nurse reminds the CNA to wash her hands and to ensure that the client is placed: Correct response: • on contact isolation. The physician asks the nurse to join him to discuss palliative care options with a terminally ill client and his family. Which statement by the nurse indicates an understanding of palliative care? Correct response: • "I'll assist with the client with his total needs." The nurse is teaching a group of unlicensed assistive personnel (UAP) about standard precautions. What information should the nurse include that best describes standard precautions? Select all that apply. Correct response: • wear gloves, a face shield, and a gown when contact with body fluids is possible • wear gloves when there is the potential for contact with a client's body fluids A client sustains a head injury after falling off of a horse and is brought to the emergency department. The nurse observes clear fluid coming from the nose. What intervention should the nurse provide? Correct response: • apply rolled gauze underneath the nose A client has a cast applied to the left leg after sustaining a fracture. What interventions can the nurse provide to avoid complications from the cast application? Select all that apply. Correct response: • monitor the tightness of the cast • keep the leg elevated above the level of the heart • administer anticoagulation per physician’s order The nurse is caring for a client on isolation precautions. The nurse exits the room and proceeds to take off the personal protective equipment (PPE). Which option identifies how the nurse should correctly remove the PPE? Correct response: • remove gloves, gown, and mask The nurse is instructing children on the best ways to prevent the spread of chickenpox. Which actions by a child with chickenpox indicates a need for further instruction? Select all that apply. Correct response: • touching a fluid filled blister • sneezing without covering the mouth and nose • kissing another child in the mouth A unit manager has four licensed practical nurses (LPN) and one registered nurse (RN) working on a unit. Which assignments would be appropriate for the LPNs? Select all that apply. Correct response: • medication nurse • wound care nurse A nurse is caring for a 2-week-old who underwent surgery to correct pyloric stenosis 6 hours ago. In addition to encouraging parental involvement in care, which postoperative nursing intervention is most important? Correct response: • Feed small amounts frequently, and evaluate the amount of emesis. A toddler with bacterial meningitis is being admitted to the inpatient unit. Which infection control measure should the nurse be prepared to use? Correct response: • airborne precautions A nurse is preparing to administer a medication to a client. Which method is best for verifying the client's identity? Correct response: • check the client's identification bracelet A nurse is helping a client with meal choices for a low-potassium diet. Which breakfast selection indicates to the nurse that the client understands the diet? Correct response: • scrambled eggs, toast, and tea The nurse is providing care for a client who has had a stroke. Since the onset of symptoms, the client has been experiencing left-sided hemianopsia. Which nursing interventions would be appropriate? Select all that apply. Correct response: • place the client’s belongings on the right side of the bed • stand on the right side of the bed when providing care Which interventions should the nurse perform prior to administering an enema to a client? Select all that apply. Correct response: • gather the supplies • verify the health care provider’s prescription • provide for client privacy • Explain the procedure to the client. Which interventions should the nurse perform prior to administering an enema to a client? Select all that apply. Correct response: • Gather the supplies. • Verify the health care provider’s prescription. • Provide for client privacy. • Explain the procedure to the client. The nurse is caring for a group of clients. Which activities by the nurse is the best example of the nurse as an interdisciplinary team member? Correct response: • recommending a physical therapy consult because of altered mobility A LPN/LVN working in a community health center is reinforcing family needs during a disaster planning drill. What should be included in the family preparedness drill? Select all that apply. Correct response: • Prepare a package of vital records. • Have extra medications and food items for dietary requirements. • Establish a place to meet in an emergency. While making rounds on the pediatric floor, a nurse finds an infant in the crib unresponsive and without respirations. Which action should the nurse take first? Correct response: • Call for assistance. A client in a long-term care facility has signed a form stating no resucitation should be provided. The client's health status rapidly deteriorates rendering the client incompetent to make decisions. During morning rounds, the nurse finds this client without vital signs. What should the nurse do next? Correct response: • Notify the health care provider that the client has no vital signs. During dinner a client suddenly begins to cough heavily, have deep inspirations, and grasp the throat. What is the nurse's immediate action? Correct response: • Ask the client if they can speak. The nurse must irrigate a gaping abdominal incision with sterile normal saline, using a piston syringe. How should the nurse proceed? Correct response: • Irrigate continuously until the solution becomes clear or all of the solution has been used. A client on bedrest with an indwelling urinary catheter informs the nurse of having discomfort in the lower abdomen. What is the first action by the nurse? Correct response: • check to see if the catheter is kinked A disaster has been reported a few miles from an area hospital. Which of the following roles should be assigned to the LVN/LPN? Correct response: • render first aid to injured clients A nurse is on duty on a medical surgical unit when the fire alarm sounds. What is the nurse's priority intervention? Correct response: • close all doors to the client rooms The nurse is caring for a group of clients. Which activities by the nurse is the best example of the nurse as an interdisciplinary team member? Correct response: • recommending a physical therapy consult because of altered mobility A nurse is providing oral care for a comatose client. Which priority nursing intervention should the nurse perform for this client? Correct response: • Position the head of bed low with the client turned laterally. A nurse is caring for a client with lower back pain who is scheduled for myelography using a water-soluble contrast dye. After the test, the nurse should place the client in which position? Correct response: • head of the bed elevated 45 degrees A nurse is caring for a client with a tracheostomy. Which equipment should the nurse gather to perform tracheostomy care? Correct response: • sterile gloves and sterile saline solution A nurse is administering morphine sulfate, as prescribed, to a client before surgery. The client asks the nurse why this medication is given preoperatively. What is the best response by the nurse? Correct response: • “Administered preoperatively, morphine sulfate will decrease the amount of general anesthesia that will be required.” A nurse is caring for a client who is recovering from an illness requiring prolonged bed rest. Based on the nursing documentation, which procedure would the nurse implement next? Correct response: • Perform active range-of-motion exercises of the legs. The nurse is caring for the four clients. Which client should the nurse see first? Correct response: • client who needs pain medication for a pain level of 9 of 10 A nurse is reinforcing education for a client with multiple sclerosis on how to reduce fatigue. What suggestion for reducing fatigue can the nurse provide? Correct response: • Rest in an air-conditioned room. [Show More]

Last updated: 1 year ago

Preview 1 out of 35 pages