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NCLEX- PN

84 terms Anna_Al-Dean91 Preview Predictor B 150 terms Alayna_Cornelius1 Preview NCLEX 153 term dec The LPN/LVN supervises 2 unlicensed assistive personnel (UAPs) caring for clients in a skilled nursing facility. Which activity requires immediate intervention by the LPN/LVN?

1.The UAP flushes the gastrostomy tube with water prior to administering acetaminophen 650mg

• The UAP obtains the daily weight on a client diagnosed with heart failure.
• The UAP wears gloves while assisting a client with ambulation.
• The UAP measures and records the BP and heart rate of a client diagnosed with a migraine headache.

1.The UAP flushes the gastrostomy tube with water prior to administering acetaminophen 650mg An unlicensed assistive personnel (UAP) assists the LPN/LVN with the care of a client diagnosed with diabetes mellitus and a stage 2 pressure injury on the right elbow. The client is confused and has limited mobility. Which observation most concerns the LPN/LVN?

• The UAP obtains the supplies needed for a sterile dressing change.
• The UAP documents the appearance of the client's pressure injury.
• The UAP leaves both side rails down.
• The UAP measures the client's blood sugar.
• The UAP leaves both side rails down.

The LPN/LVN cares for a client 1 day after a bowel resection for the treatment of diverticulitis. Which Laboratory result should be reported immediately to the health care provide

• Prothrombin time (PT) 10.5 seconds.
• WBC count 12,000/mm3 (12 x 10°/L).
• Hemoglobin level 6.9 g/dL (6.9 g/L).
• Platelet count 162,000/n
• Hemoglobin level 6.9 g/dL (6.9 g/L).

The LPN/LVN cares for an 8-year-old in the outpatient clinic. The child reports right lower quadrant (RLQ) abdominal pain, "feeling warm," and vomiting. Which observation most concerns the LPN/LVN?

• The child's cheeks are flushed.
• The child's BP is 100/60 mm Hg.
• The child states, "I feel like I could go throw up again!"
• The child states, "The pain had stopped, but now it hurts bad!"
• The child states, "The pain had stopped, but now it hurts bad!"

The LPN/LVN cares for the client diagnosed with herpes zoster. Which question is most important for the LPN/LVN to ask the client?

• "At what age did you have chickenpox?"
• "Are you allergic to any broad-spectrum antibiotics?"
• "Are you concerned about appearance of the blisters on your skin?"
• Are you exposed to people not immunized against varicella zoster?
• Are you exposed to people not immunized against varicella zoster?

The LPN/LVN cares for a client diagnosed with bacterial pneumonia. The LPN/LVN notes the client is diaphoretic, uses accessory muscles to breathe, and has a respiratory rate of 30 breaths per minute. Which action by the LPN/LVN is most appropriate?

• Determine when the last IV antibiotic dose was given.
• Notify the primary RN immediately.
• Obtain and record the pulse oximetry reading.
• Auscultate anterior and posterior lung sounds.
• Notify the primary RN immediately.

The LPN/LVN prepares to administer newly prescribed benazepril and verapamil to the client. The client reports having experienced shortness of breath and hives immediately after receiving diltiazem and clonidine many years ago. Which action by the LPN/LVN is most appropriate?

• Administer both benazepril and verapamil as prescribed and observe the client.
• Notify the primary RN of the previous allergy to diltiazem.
• Notify the primary RN of the previous allergy to clonidine.
• Administer verapamil and notify the primary RN of its effect.
• Notify the primary RN of the previous allergy to diltiazem.

The LPN/LVN cares for 4 clients on the medical-surgical unit, Which client should be seen first?

• Client 1 reports unilateral, throbbing headache and photophobia; recent diagnosis of migraine headaches.
• Client 2 reports irregular arm, leg, and tongue movements; recent diagnosis of Huntington disease. __
• Client 3 reports progressive, ascending motor weakness; recent diagnosis of Guillain-Barré syndrome.
• Client 4 reports tinnitus, pressure in the left ear, and nausea and vomiting; recent diagnosis of Ménière disease

. Client 3 reports progressive, ascending motor weakness; recent diagnosis of Guillain-Barré syndrome.The LPN/LVN on a telemetry unit assists the RN in caring for an adult client admitted for observation. Suddenly, the client reports chest pressure, left jaw pain, and shortness of breath. Which action would receive highest priority by the LPN/LUN?

• Administer morphine 4 mg IV. |
• Notify the primary RN.
• Review the client's last electrocardiogram (ECG).
• Administer aspirin 325 mg PO.(0) Explanation
• Notify the primary RN.

The LPN/LVN reinforces teaching for a client scheduled to have a prostate-specific antigen (PSA) level drawn. The LPN/LVN knows teaching about PSA and prostate cancer is effective if the client makes which statement? (Select all that apply.)

• "A low PSA level means I probably have prostate cancer."
• "Prostate cancer is most prevalent in African Americans."
• "A strong family history of breast cancer increases my risk of developing prostate cancer."
• "Prostate cancer most often metastasizes to the bones."
• "Normal PSA level is 8 ng/mL (8 ug/L)."
• "Prostate cancer is most prevalent in African Americans."
• "A strong family history of breast cancer increases my risk of developing prostate cancer."
• "Prostate cancer most often metastasizes to the bones

The LPN/LVN reinforces teaching for a client prescribed vitamin D supplements for the treatment of osteoporosis. The LPN/LVN knows teaching is effective if the client makes which statement? (Select all that apply.)

• "It's important for me take my vitamin D supplement so I don't develop osteomalacia,"
• "Too much vitamin D can cause hypercalcemia."
• "Fortified milk is not a good source of vitamin D.""

4.Vitamin D is needed for the absorption of calcium and phosphorus

• "I will take the vitamin D pills daily as prescribes"
• "It's important for me take my vitamin D supplement so I don't develop osteomalacia,"
• "Too much vitamin D can cause hypercalcemia."
• "Fortified milk is not a good source of vitamin D.""

4.Vitamin D is needed for the absorption of calcium and phosphorus

• "I will take the vitamin D pills daily as prescribes"

The LPN/LVN cares for a client diagnosed with coronary artery disease, hypertension, and hyperlipidemia. The LPN/LVN is concerned if the unlicensed assistive personnel (UAP) provides the client with which dinner tray?

1.Chicken and dumplings with added bouillon cubes, buttered ** biscuits, and whole milk.

• Baked chicken with 2 pieces of whole grain bread, an apple, ** and glass of lemonade.
• Turkey bacon and lettuce wraps with fresh green beans, banana, and water.
• Baked fish with broccoli, asparagus, applesauce, and low-fat milk.

1.Chicken and dumplings with added bouillon cubes, buttered ** biscuits, and whole milk.The nurse is caring for a client with peptic ulcer disease (PUD) who vomited 150 mL of blood-tinged green liquid. Which of the client's laboratory test results would be a priority to check?

• serum pH
• hematocrit (HCT) (key)
• serum sodium level
• blood urea nitrogen (BUN
• hematocrit (HCT)

The nurse is talking with a client who had a subtotal gastrectomy 1 month ago. Which of the following statements by the client would be a priority to follow up?

• "I occasionally take an over-the-counter (OTC) laxative."
• "I eat several small meals each day."
• "I avoid drinking liquids with meals."
• "I feel tired all the time." (key
• "I feel tired all the time." (key

The nurse is reinforcing teaching with a female client who is receiving prescribed atorvastatin. Which of the following information should the nurse reinforce?

• "Maintain your usual diet while taking the medication."
• "Continue to take atorvastatin if you become pregnant."
• "Report muscle aches to your primary health care provider."
• "Take the medication 1 hour before or 2 hours after a meal."
• "Report muscle aches to your primary health care provider."

The nurse is contributing to a staff education program about advance directives. Which of the following information should the nurse suggest including in the program? Select all that apply.

• "A living will provides information about the client's wishes regarding medical treatment."
• "Health care facilities are required to provide clients with information about advance directives
• "Advance directives are legally binding and cannot be changed by the client once they are written."
• "It is unnecessary to have a power of attorney for health care if the client already has a living will."
• "A power of attorney for health care allows a designated person to make health care decisions for the client when the client is unable to do

so."

• "A living will provides information about the client's wishes regarding medical treatment."
• "Health care facilities are required to provide clients with information about advance directives."
• "A power of attorney for health care allows a designated person to make health care decisions for the client when the client is unable to do

so." The nurse is caring for a client who has an abdominal wound infected with methicillin-resistant Staphylococcus aureus (MRSA). Which of the following infection control precautions should the nurse implement?

• Wear a surgical mask when changing the client's abdominal wound dressing.
• Limit the amount of time that visitors spend with the client to 30 minutes each shift.
• Place a surgical mask on the client when transporting the client to the radiology department.
• Check the client's blood pressure by using a stethoscope designated for the client's use only.
• Check the client's blood pressure by using a stethoscope designated for the client's use only. (

The nurse has reinforced teaching with the parents of a 2-day-old, full-term newborn. Which of the following statements by a parent would indicate a correct understanding of the teaching?

• "The swollen area on the side of my baby's head will go away on its own."
• "The primary health care provider will measure my baby's head circumference every week."
• "The elevated, red birthmark on my baby's head will be removed if the birthmark gets bigger."
• "The fontanel at the front of my baby's head should be indented when my baby is held upright."
• "The swollen area on the side of my baby's head will go away on its own."

The nurse is contributing to the plan of care of a client with mild Alzheimer's disease (AD) who has recently started wandering and spends approximately 6 hours each day sleeping. Which of the following outcomes would be appropriate for the nurse to recommend for the client's plan of care?

• The client will stop wandering.
• The client will take 2 to 3 naps during the day.
• The client will wander within designated areas.
• The client will identify the impact of activity on the sleep cycle
• The client will wander within designated areas.