The LPN/LVN knows that which of the following laboratory findings reflects the signs and symptoms of infection?
1. Serum creatinine level of 2.4 mg/dL.
2. AST (SGOT) 15 U/L.
3. White blood cell count of 16,000/mm3.
4. White blood cell count of 4,000/mm3.
Strategy: Think about each answer.
(1)measures renal function; normal is 0.5 to 1.5 mg/dL; elevated in acute and chronic renal failure
(2)measures damage to liver and heart; normal is 10 to 40 U/L
(3)CORRECT�normal range is 4,500 to 11,000/mm3; elevation
The nurse cares for a client diagnosed with spinal cord injury at the level of T1. The nurse notes profuse sweating, and the client complains of a pounding headache and nasal stuffiness. Arrange the following actions in the proper sequence from FIRST to L
Strategy:
Determine how best to decrease client's blood pressure.
(1) Place the client in a sitting position: lowers blood pressure immediately
(2) Check the Foley catheter tubing for kinks or obstruction: most common cause is distended bladder or constip
To measure the pulse during adult cardiopulmonary resuscitation (CPR), the LPN/LVN should use which of the following arteries?
1. The femoral artery.
2. The radial artery.
3. The carotid artery.
4. The brachial artery.
Strategy: Think about the location of each artery.
(1) located below inguinal ligament, midway between symphysis pubis and anterior superior iliac spine; assess status of circulation to leg
(2) found on thumb side of forearm at wrist; used to assess perip
The nurse enters the client's room during a blood transfusion. The LPN/LVN should attend to which of the following sign/symptom FIRST?
1. Blood pressure 145/80 mm Hg.
2. The client complains of shortness of breath.
3. The client complains of pruritus.
4.
Strategy: "FIRST" indicates priority.
(1) transfusion reactions usually cause hypotension; borderline systolic elevation is considered to be related to psychological stress
(2) CORRECT�dyspnea may indicate an allergic reaction with a decrease in caliber o
The LPN/LVN understands that psoriasis is which of the following?
1. A chronic hereditary disease.
2. An acute infectious disease.
3. A viral disease.
4. A cystic, self-limiting disease.
The LPN/LVN understands that psoriasis is which of the following?
1. A chronic hereditary disease.
2. An acute infectious disease.
3. A viral disease.
4. A cystic, self-limiting disease.
The home care LPN/LVN monitors a client diagnosed with cancer of the lung. The client states that she has awakened with a severe headache several mornings during the past week. She also admits to becoming suddenly nauseated, has vomiting, and notices that
Strategy: "BEST" indicates that discrimination is required to answer the question.
(1)manifestations indicate the possibility of metastasis to the brain; LPN/LVN should contact the supervising nurse
(2)indicates a complication of lung cancer and should be
An elderly client is lost in the mountains for 3 days, and after rescue is admitted to the unit with a diagnosis of dehydration. In addition to monitoring for signs and symptoms of dehydration, it is MOST important for the LPN/LVN to monitor for which of
Strategy: "MOST important" indicates priority.
(1) fluid volume deficit causes hypotension, rapid and weak pulse, and an elevated temperature; cardiac dysrhythmias are more significant safety risks to the client
(2) more common in fluid volume excess
(3)
The LPN/LVN auscultates a client's breath sounds. The LPN/LVN knows that vesicular sounds will have which of the following characteristics?
1. Loud, coarse, blowing sound heard over the trachea.
2. Musical sounds or vibration commonly heard on expiration.
Strategy: Think about each answer.
(1)describes bronchial breath sounds; normal sounds
(2)describes rhonchi; adventitious sounds caused by fluid or inflammation
(3)describes bronchovesicular sounds; normal sounds
(4)CORRECT�describes vesicular sounds, nor
When the LPN/LVN delivers external cardiac compressions during cardiopulmonary resuscitation, it is MOST important for the LPN/LVN to take which of the following actions?
1. Maintain a position close to the victim's side with the knees apart.
2. Maintain
Strategy: Determine the outcome of each answer. Is it desired?
(1) one rescuer�face victim, on knees, parallel to victim's sternum; two rescuers�one person faces victim kneeling parallel to victim's head, second person on opposite side facing victim, knee
The LPN/LVN identifies that which of the following clients is MOST likely to develop seizures?
1. The client who is allergic to shellfish.
2. The client who leads a sedentary lifestyle.
3. The client who has a brain tumor.
4. The client who is 62 years ol
Strategy: "MOST likely" indicates that discrimination is required to answer the question.
(1.) more likely to experience cardiovascular shock
(2.) may result in inability to respond to sudden increase in physical activity or response to sustained emotiona
The LPN/LVN cares for a client diagnosed with leukemia. The client tells the LPN/LVN that he is having abdominal pain. The LPN/LVN understands that the abdominal pain is due to which of the following?
1. Hepatosplenomegaly.
2. Side effects of medication.
Strategy: Think about each answer.
(1)CORRECT�clients with leukemia develop enlarged liver and spleen, causing the abdominal pain
(2)side effects of chemotherapy include bone marrow depression, alopecia, and nausea and vomiting
(3)may occur due to chemoth
The LPN/LVN understands that which of the following is the MOST significant risk factor for developing cancer?
1. Advancing age.
2. Smoking tobacco.
3. Drinking alcohol.
4. Family history of cancer.
Strategy: "MOST significant" indicates that discrimination is required to answer the question.
(1)CORRECT�single most significant risk factor; 50% of all cancers occur in people older than 65 years of age
(2)tobacco is a carcinogen that contributes to lun
The LPN/LVN recognizes that which of the following is an early symptom of gastric cancer?
1. Occult blood in the stool.
2. Vomiting.
3. Iron-deficiency anemia.
4. Abdominal discomfort relieved with antacids.
Strategy: Think about each answer.
(1) indicates advanced gastric cancer
(2) indicates advanced gastric cancer
(3) indicates advanced gastric cancer
(4) CORRECT�other indications include indigestion, loss of appetite, bloated feeling, and weight loss
A client with ovarian cancer experiences severe pain. Which of the following principles should the LPN/LVN apply?
1. Caution must be used to prevent narcotic addiction.
2. Cancer pain is often psychological in origin.
3. Pain medication should be given on
Strategy: Think about each answer.
(1)primary focus in the management of clients with pain related to terminal illness is narcotic tolerance rather than addiction
(2)all pain is real; pain is "whatever the person experiencing the pain says it is"; goal is
The LPN/LVN cares for a child experiencing grand mal seizures. The LPN/LVN attempts to identify the "aura" of a child with grand mal seizures. The LPN/LVN identifies which of the following statements as BEST describing an "aura"?
1. A state of consciousne
Strategy: Think about each answer.
(1.) unconsciousness occurs during generalized seizures and complex partial seizures due to excessive discharge of electrical activity within the brain
(2.) CORRECT�an "aura" can be described as a series of unusual sensa
The LPN/LVN expects the client to experience which of the following physiological changes during episodes of acute pain?
1. Decreased blood pressure.
2. Decreased skin temperature.
3. Decreased heart rate.
4. Decreased respiration.
Strategy: Think about each answer.
(1)blood pressure and heart rate increase, which increases blood flow to brain and muscles
(2)CORRECT�increased perspiration and vasoconstriction occur during acute pain episodes, thereby cooling off the skin
(3)heart ra
The LPN/LVN contributes to the care for a client admitted to the emergency room after an automobile accident. The client complains of dizziness, and the health care provider suspects a head injury. The LPN/LVN should intervene if which of the following is
Strategy: "Should intervene" indicates something is wrong.
(1.) CORRECT�clients with head injuries are treated as spinal cord injuries until x-rays are completed; need to obtain assistance to immobilize the client's neck should come before x-rays
(2.) cli
The LPN/LVN assists with the discharge teaching for a client diagnosed with chronic obstructive pulmonary disease (COPD). When the client's wife asks why the concentration of the supplemental oxygen cannot be increased when the client is having difficulty
Strategy: Think about each answer.
(1) CORRECT�progressive loss of recoil of lung tissue results in air trapped in the lung tissue as well as an arterial hypercapnia;hypoxemia stimulates the client to breathe; sudden increase of oxygen (O2) in the blood c
The LPN/LVN identifies that which of the following findings are characteristic of a client with chronic pain?
1. Weight loss or gain, fatigue.
2. Obesity, restlessness, and thirst.
3. Anxiety, insomnia, and memory loss.
4. Quick response to analgesics.
Strategy: Think about each answer.
(1)CORRECT�chronic pain is an episode of pain that lasts for 6 months or more; serves no useful function and becomes a problem of its own; chronic pain often becomes a disability; in some clients, weight loss occurs beca
The LPN/LVN assists in the assessment of a client who sustained burns in an apartment fire. The LPN/LVN should IMMEDIATELY report to the supervising nurse which of the following signs/symptoms?
1. The client has singed nasal hair.
2. The client's blood pr
Strategy: Determine how each answer relates to burns.
(1) CORRECT�intra-oral burns and singed nasal hairs indicate potentially serious injuries to respiratory system; should be observed for progressive hoarseness, brassy cough, drooling or exhibiting diff
The LPN/LVN cares for a client diagnosed with colorectal cancer. The LPN/LVN understands that eating which of the following foods may have contributed to the client developing colon cancer?
1. Broccoli and cabbage.
2. Fried red meat.
3. Water.
4. Oranges
Strategy: Think about each answer.
(1)food from cabbage family should be consumed to decrease the incidence of colon cancer
(2)CORRECT�contributes to the risk of developing colon cancer; other foods to avoid include animal fats, broiled meats and fish, an
The LPN/LVN assists in the teaching of a client diagnosed with asthma. The LPN/LVN determines that further teaching is necessary if the client states which of the following?
1. "I'm going to have to replace my wool rugs and feather pillows."
2. "I can no
Strategy: "Further teaching is necessary" indicates incorrect information.
(1) will remove allergens that can trigger an asthmatic attack
(2) true statement; can trigger an allergic reaction; should avoid smoke, fireplaces, dust, mold, and weather changes
The LPN/LVN contributes to the teaching about home care instructions for a client diagnosed with angina. The LPN/LVN determines teaching is effective if the client makes which of the following statements?
1. "If I have chest pain, I should contact my phys
Strategy: "Teaching is effective" indicates accurate information.
(1) contact physician if chest pain hasn't been relieved by nitroglycerin, 1 tablet at 5 min interval x 3; physician often difficult to reach; if reached cannot offer appropriate assistance
The LPN/LVN cares for a client admitted to the unit with a diagnosis of acute myocardial infarction. The LPN/LVN identifies this client is attached to a cardiac monitor for which of the following reasons?
1. To monitor client's condition closely without b
Strategy: Think about each answer.
(1) does promote rest by providing assessment data by way of mechanical assessment; rest is important but is not the most relevant rationale for monitoring the client's cardiac status; early detection is the key to MI re
An elderly client has a medical history that includes hypertension. A public health LPN/LVN visits the client regularly and on each visit records the vital signs. Which of the following findings does the LPN/LVN expect for this client?
1. Temperature 99.9
Strategy: Think about each answer.
(1) temperature too high
(2) temperature and pulse too high
(3) blood pressure usually higher with hypertension
(4) CORRECT�in the elderly, body temperature may decrease; temperature is normal for elderly client; blood p
The LPN/LVN understands that bedrest following a myocardial infarction (MI) BEST achieves which of the following?
1. Facilitates accurate cardiac monitoring.
2. Promotes a restful atmosphere.
3. Decreases the workload on the heart.
4. Allows regeneration
Strategy: "BEST" indicates discrimination may be required to answer the question.
(1) accurate cardiac monitoring can be achieved if client is ambulatory
(2) a calm environment will decrease anxiety, which will help relieve chest pain
(3) CORRECT�client h
A nursing assistant tells the LPN/LVN that a client is having an allergic reaction to the IV medication administered 5 minutes ago. Which of the following actions should the LPN/LVN take FIRST?
1. Administer Benadryl 50 mg PO stat.
2. Place Code Blue cart
Strategy: "FIRST" indicates priority.
(1) drug may be administered orally if reaction is mild; would need to assess client prior to administering
(2) need more information before deciding client may be at risk for anaphylaxis; epinephrine may be administe
A father is concerned about his son's detached retina. He asks the LPN/LVN if a retinal detachment can be hereditary. The BEST response by the LPN/LVN includes which of the following?
1. "Have any of your other children had a detached retina?"
2. "There a
Strategy: "BEST" indicates that discrimination is required to answer the question.
(1.) caused by trauma, aging process, diabetes, and tumors
(2.) CORRECT�this is the best response the LPN/LVN can give the boy's father because there are no certain causes
The LPN/LVN on the surgical unit cares for a client after an ileostomy. Which of the following actions should the LPN/LVN take FIRST?
1. Empty the ileostomy bag from the bottom.
2. Apply lotion to the skin around the stoma.
3. Cover the ileostomy with thr
Strategy: "FIRST" indicates priority.
(1) implementation; empty the pouch when it is 1/3 to 1/2 full; should monitor the characteristics frequently
(2) implementation; skin barrier required due to proteolytic enzymes and bile salts that are present in the
The LPN/LVN identifies which of the following risk factors as MOST likely to contribute to an elevation of client's blood pressure?
1. A high-pressure job.
2. Daily vitamins.
3. One glass of wine a day.
4. Daily exercise.
Strategy: "MOST likely" indicates that discrimination is required to answer the question.
(1)CORRECT�stress is an important factor in the development of hypertension; other risk factors include family history of hypertension, high sodium intake, and exces
The LPN/LVN cares for the client receiving magnesium sulfate IV. The LPN/LVN notes that the client's deep tendon reflexes are decreased from +1 to 0. Which action should the LPN/LVN take FIRST?
1. Document the results in the patient's chart.
2. Place the
Strategy: "FIRST" indicates priority.
(1) magnesium sulfate given to prevent and treat convulsions; decreased deep tendon reflexes indicates magnesium toxicity; stop the magnesium to prevent further decline
(2) appropriate action, but would not be the fir
The LPN/LVN teaches an adult wellness class about how to prevent skin cancer. Which of the following statements by the LPN/LVN is BEST?
1. "Wear sunscreen if the temperature is above 80.0�F (26.7�C)."
2. "Wear a hat during the summer months."
3. "Stay ind
Strategy: "BEST" indicates discrimination is required to answer the question.
(1) wear sunscreen when going outdoors regardless of the temperature
(2) wear hat and sunglasses when out in the sun
(3) CORRECT�exposure to the sun is a major risk factor to de