NCLEX LPN Basic Care and Comfort

NCLEX LPN Basic Care and Comfort ScienceMedicineNursing IAMStudmuffin Save NCLEX Basic Care & Comfort 37 terms nurseathrtPreview Basic Care and Comfort NCLEX que...44 terms Jessi_Austin7Preview Exam Cram NCLEX-PN PRACTICE Q...103 terms summer3266Preview NCLEX 116 term lau The LPN/LVN assists in instructing a client with a history of repeated urinary tract infections. Which of the following statements, if made by the client to the LPN/LVN, indicates the need for further teaching?

• "I can go all day without emptying my bladder."
• "I drink two liters of fluid every day."
• "I do not use bubble bath."
• "I drink cranberry juice each day."

Strategy: "Need for further teaching" indicates incorrect information.(1) CORRECT—should empty the bladder every 4 hours even if there is no urge; urinary stasis increases the risk of microorganism growth (2) adequate fluid intake reduces the risk of cystitis.(3) bubble bath, nylon underwear, and scented toilet tissue are irritating; clients using bubble bath tend to develop cystitis (4) makes urine acidic, which decreases incidence of infection

The LPN/LVN cares for a client with a colostomy. The client is especially concerned about controlling odor and gas. The LPN/LVN asks the client what actions the client has taken to prevent gas and odors. The LPN/LVN should intervene if the client states which of the following?

Select all that apply:

• " I place a breath mint inside the colostomy pouch."
• " I eat onions, beans, and cucumbers."
• " I drink cranberry juice and buttermilk."
• " I eat crackers, toast, and yogurt."
• " I use a commercially prepared deodorizer inside the pouch."
• " I chew gum when I get hungry because I skipped a meal."

Determine the outcome of each answer. Is it desired?(1.) appropriate behavior, eliminates odors in the pouch (2.) CORRECT— avoid these foods because they contribute to gas production (3.) appropriate behavior; helps prevent odor; eating parsley and yogurt is also helpful (4.) helps prevent gas (5.) helps eliminate odors (6.) CORRECT— chewing gum, skipping meals, drinking beer, and smoking contribute to the production of flatus The LPN/LVN notes that an elderly client has a reddened area on the coccyx. Which of the following actions should the LPN/LVN take FIRST?

• Observe the area every 4 hours.
• Reposition the client every 1 to 2 hours.
• Massage the reddened area four times per day.
• Place the client in a semi-reclining position.

The LPN/LVN notes that an elderly client has a reddened area on the coccyx. Which of the following actions should the LPN/LVN take FIRST?

• Observe the area every 4 hours.
• Reposition the client every 1 to 2 hours.
• Massage the reddened area four times per day.
• Place the client in a semi-reclining position.

Show/hide explanation

Strategy: "FIRST" indicates priority.

(1)this situation does not require further assessment (2)CORRECT—frequent change in position will relieve pressure on client's skin; encourage client to shift weight every 15 minutes; use pillow to relieve pressure over bony prominences (3)do not massage reddened area; causes damage to capillaries and deep tissues (4)causes shearing force on sacral area; shearing occurs when client is pulled or allowed to slump in the bed

A client diagnosed with Parkinson's disease has tremors in both upper arms. The LPN/LVN observes the tremors disappear as the client unbuttons his shirt. Which of the following statements illustrates the MOST ACCURATE understanding by the LPN/LVN about the tremors?

• Tremors are psychological and can be controlled at will.
• The severity of tremors decreases when attention is diverted by activity.
• Tremors are unexplainable.
• Tremors disappear with rest.

Strategy: Think about each answer.

(1.) tremors are physiological (2.) CORRECT—clients with Parkinson's disease usually exhibit tremors only at rest; if the client is given an activity to perform, the tremors seem to go away due to the diversion (3.) decreased dopamine causes uninhibited excitatory messages by acetylcholine-producing neurons in the basal ganglia (4.) will decrease with activity A home care LPN/LVN monitors a client diagnosed with Alzheimer's disease who is receiving tube feedings. The LPN/LVN observes the client's spouse administer a tube feeding to the client. The LPN/LVN should intervene if which of the following is observed?

• The client's spouse changes the bag every 24 hours.
• The client's spouse administers feeding directly from the refrigerator.
• The client's spouse checks for residual immediately before each feeding.
• The client's spouse stops the feeding if client becomes restless.

Strategy: "Nurse should intervene" indicates an incorrect behavior.

(1) bacterial growth will be at unsafe level if feeding is left at room temperature longer than 24 hours (2) CORRECT—should be at room temperature; instilling cold solution directly into the gastric vault will cause cramping; normally, solution is warmed by the oral cavity and esophagus before reaching the gastric mucosa (3) if residual is the same as infused amount, the volume is too great, infusion is too rapid, or peristalsis is inadequate; normal residual is 90 cc; greater than this amount needs to be reported to health care provider (4) client with Alzheimer's may not be able to communicate discomfort

The LPN/LVN supervises as a student nurse inserts an indwelling urinary catheter in a female client. The LPN/LVN notes that the catheter was inserted into the client's vagina. Which of the following actions by the LPN/LVN is MOST appropriate?

• Leave the catheter in place and obtain a new catheterization kit.
• Explain to the student nurse how costly it is to make this mistake.
• Remove the catheter and insert a new catheter.
• Complete an incident report.

Strategy: "MOST appropriate" indicates that discrimination is required to answer the question.(1) CORRECT—the misplaced catheter acts as a landmark; obtain a new catheter for the staff member to insert (2) follow up with staff member after the procedure is completed (3) should leave catheter in place so that mistake will not be repeated (4) incident report is documentation of an abnormal activity that placed client or staff member at risk; insertion of catheter in vagina does neither The LPN/LVN assists in the care of a client diagnosed with esophageal diverticula. The LPN/LPN determines that care of this client is effective if which of the following is observed?

• The client's stool specimen is negative for occult blood.
• The client gained 4 pounds during the previous 30 days.
• The client has decreased signs/symptoms of inflammation/infection.
• The client has decreased episodes of pyrosis.

Strategy: Look for a positive outcome.

(1) more commonly associated with PUD (peptic ulcer disease); indications include pain 2-3 hours after meals; food intake relieves the pain (2) CORRECT—primary problem is dysphagia, resulting in inadequate food intake; primary goal is to increase nutritional status; diverticula is saclike outpouching of the lining of the GI tract that goes through the muscle layer (3) can become inflamed if food is trapped in the sac; dysphagia is a problem clients commonly experience (4) heartburn; more commonly associated with gastric-esophageal reflux disease (GERD)