NCLEX LPN Reduction of Risk Potential

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ATI REDUCTION OF RISK POTENTI...

66 terms shelby__chinen Preview NCLEX 15 terms hail The LPN/LVN understands that hematocrit measures which of the following?

• The oxygen-carrying capacity of the blood.
• The ratio of red blood cells to fluid volume.
• The number of red blood cells in 100 ml of blood.
• The ratio of red blood cells to white blood cells.

Strategy: Think about each answer.

(1) describes hemoglobin; man 13-18 g/dL; woman 12-15 g/dL; child 11-12.5 g/dL (2) CORRECT—the ratio of red blood cells to fluid volume; man 42-50%; woman 40-48%; child 35-45% (3) red blood cell count determines the actual number of cells in relation to volume; man 4.6-6.2 million/mm3; woman 4.2-5.4 million/mm3; child 3.2-5.2 million/mm3 (4) white blood cell count establishes amount and maturity of white blood cell elements; adult 5,000-10,000/mm3; child 5,000-13,000/mm3 The LPN/LVN instructs a postoperative client about how to use an incentive spirometer. The LPN/LVN determines teaching has been effective if the client makes which of the following statements?

• "I should take a deep breath and blow into the

mouthpiece."

• "I'm glad that I only have to do this twice a day."
• "I should ask for pain medication before using the

spirometer."

• "I should lie down to use the incentive spirometer."

Strategy: "Teaching is effective" indicates correct information.

(1) appropriate process is to determine the amount of air the client can forcibly inhale; LPN/LVN's responsibility is to assure conditions that promote maximum function exists; client does not blow into the incentive spirometer (2) recommended that client take 10 deep breaths per hour (3) CORRECT—the incentive spirometer is used after thoracic and abdominal surgery to prevent atelectasis, to encourage deep inspirations; assess the client's level of pain and administer pain medication (4) maximal lung expansion will occur if client is sitting up

Which of the following actions is essential for the LPN/LVN to take after administering preoperative medication to a client?

• Ensure that the operative permit is signed.
• Discuss the client's feelings about surgery.
• Raise the side rails of the bed.
• Tell the client what to expect in the operating roo

Strategy: "Essential" indicates that discrimination is required to answer the question.(1)operative permit should be signed before preoperative medication is administered; otherwise client would be impaired and incapable of signing the permit (2)safety takes priority over psychosocial needs (3)CORRECT—because preoperative medications often include sedatives or narcotics, client will be impaired after the injection;will prevent injury to the client (4)one condition necessary for teaching/learning is to have an alert student; if preoperative medication is administered before teaching, client would be impaired and unable to learn The LPN/LVN suctions a client by way of his tracheostomy. When performing this procedure, in which of the following positions should the client's head be placed to clear his right bronchus of debris?

• The client's head turned to the left.
• The client's head turned to the right.
• The client's head tilted forward toward the chest.
• The client's head tilted backward even with his

shoulders.

Strategy: Determine the outcome of each answer. Is it desired?

(1) CORRECT—when a tracheostomy client is suctioned, the head should be positioned to the side opposite from that of the bronchus being suctioned; clearing the right bronchus is therefore best accomplished by turning client's head to the left (2) appropriate position to suction the left bronchus (3) position will impair access to the trachea (4) causes hyperextension of the neck; trachea would be flexed; easier to suction if trachea is straight The nurse prepares a client for surgery. Place the following preoperative activities in the correct sequence from FIRST action to LAST. All options must be used.

(1) Verify that operative permit is signed: perform first

before continuing preparation; confirm that lab results are posted

(2) Obtain and record the vital signs: provides baseline

for anesthesiologist

(3) Ask the client to empty the bladder: do not allow

client to ambulate after receiving preoperative medication

(4) Instruct the client to remain in bed: safety measure;

raise side rails and put bed in low position

(5) Administer preoperative medication: provide all

nursing care prior to administering preoperative medication

(1) Verify that operative permit is signed: perform first before continuing

preparation; confirm that lab results are posted

(2) Obtain and record the vital signs: provides baseline for anesthesiologist

(3) Ask the client to empty the bladder: do not allow client to ambulate after

receiving preoperative medication (4) Instruct the client to remain in bed: safety measure; raise side rails and put bed in low position

(5) Administer preoperative medication: provide all nursing care prior to

administering preoperative medication

The LPN/LVN cares for a client after surgery. The LPN/LVN notes that the client last voided before surgery 10 hours ago. Which of the following actions should the LPN/LVN take FIRST?

• Insert a catheter into the bladder.
• Encourage client to take sips of water.
• Inform the nursing supervisor right away.
• Palpate for bladder distention.

Strategy: "FIRST" indicates priority.

(1)assess before implementing (2)assess the status of the bladder (3)perform assessment of client before contacting the nursing supervisor (4)CORRECT—primary focus is renal function and return of bladder function; best source is to examine the bladder; if renal function is occurring, urine will be in the bladder; if client has problem with voiding, bladder will be distended

Strategy: Think about each answer.

(1) may be scheduled eventually to determine the extent of damage and the appropriate intervention, but initially is not the top priority (2) CORRECT—pain reduction is the top priority because it reduces the oxygen (O2) demand on impaired cardiac tissue; primary goal is to prevent further damage to the heart muscle; reducing O2 demand is the BEST approach (3) assessing cardiac rhythm would be second to relieving chest pain; the rhythm helps the nurse monitor the impending danger to the client; relieving the chest pain reduces the oxygen demand, resulting in reduction of risk to the client; the rhythm warns the nurse of the client's needs (4) need to collect crucial evidence such as drug allergies, implanted organs, or diabetes; comprehensive health history would wait until client is stabilized or can be obtained from another person The LPN/LVN cares for a client diagnosed with cholecystitis. The client says to the nurse, "I don't understand why my right shoulder hurts when the gallbladder is not by my shoulder!" Which of the following responses by the nurse is BEST?

• "Sometimes small pieces of the gallstones break off and

travel to other parts of the body."

• "There is an invisible connection between the

gallbladder and the right shoulder."

• "The gallbladder is on the right side of the body and so

is that shoulder."

• "Your shoulder became tense because you were

guarding against the gallbladder pain." Strategy: "BEST" indicates that discrimination may be required to answer the question.(1.) gallstones do not become emboli (2.) CORRECT— describes referred pain; when visceral branch of a pain receptor fiber is stimulated, vasodilation and pain may occur in a distant body area; right shoulder or scapula is the referred pain site for gallbladder (3.) anatomically correct but is not the best explanation (4.) possible; not the best explanation

Strategy: Gather data before implementing.

(1) nurse should follow up on client's observation (2) does not respond to what the client is saying (3) CORRECT—2 to 4 cc/min is considered the normal range of IV solution for an adult; LPN/LVN should review client's record to determine how much IV fluid the client received (4) literal response to client The LPN/LVN should lubricate the catheter used to suction a client's tracheostomy with which of the following?

• Sterile water.
• Mineral oil.
• Hydrogen peroxide.
• K-Y jelly.

Strategy: Determine the outcome of each answer. Is it desired?

(1) CORRECT—water is the preferred lubricant because it won't irritate the tissues; can also use sterile saline (2) aspiration of oil molecules can result in pneumonia; mineral oil is an emollient laxative (3) cleansing solution used to clean wound and inflamed mucous membranes; diluted with equal parts of water; should not risk introducing contents into the airway because foams when in contact with secretions or tissue (4) is water-soluble lubricant in gel form, introducing catheter covered with gel could result in aspiration of the material .The LPN/LVN monitors a client receiving a blood transfusion. The LPN/LVN should intervene if which of the following is observed?

• The blood is infused in 3 h.
• The blood is started with normal saline.
• The blood is started 15 min after arriving from the

blood bank.

• The blood is infused at 10 mL/min for the first 15 min.

Strategy: "Should intervene" indicates something is wrong.

(1) blood should be infused within 4 h of refrigeration (2) only use normal saline to prevent clotting or hemolysis of blood cells (3) should be administered as soon as possible after removal from the blood bank (4) CORRECT—blood should be run slowly at first (no faster than 5 mL/min for the first 15 min) with nurse in attendance; if no reaction, regulate blood to the prescribed rate A client requires an emergency tracheostomy. In caring for the client's tracheostomy, the LPN/LVN should take which of the following actions?

• Suction every hour.
• Clean the inner cannula after suctioning.
• Clean the site every 4 h.
• Hyperextend the client's neck to maintain patency.

Strategy: Think about the outcome of each answer. Is it desired?

(1) suction only when needed; suctioning causes damage to the mucosa, bleeding, and bronchospasm; suctioning usually needed when the following are assessed: noisy secretions, crackles, rhonchi, restlessness, increased pulse and respiratory rate; hyperoxygenate before suctioning (2) perform tracheostomy care whether or not client requires suctioning; tracheostomy care every 8 h or as needed (3) CORRECT—cleaning the site every 4 h will help prevent infection (4) can decrease airway size and increase risks for expulsion of tracheostomy