NCLEX LPN MANAGEMENT OF CARE FINAL

NCLEX LPN MANAGEMENT OF CARE FINAL

TEST 2024 | ALREADY GRADED A+ |

GUARANTEED PASS

The LPN/LVN cares for a client diagnosed with polycythemia Vera. It is MOST important for the LPN/LVN to instruct the nursing assistants to perform which of the following?

• Massage the lower limbs vigorously during the morning bath.
• Assist the client with long, early morning walks.
• Apply antipruritic lotion after completing the client's bath.

4. Measure vital signs q 4 hours. - ANSWER-Strategy: "MOST important"

indicates discrimination is required to answer the question.

(1) polycythemia is an increased volume of red blood cells; because of the increased number of RBCs, client is at risk for clot formation; vigorous massage is contraindicated

(2) because of excessive RBCs, client will have reduced oxygen exchange, resulting in fatigue, intermittent claudication, and dyspnea; extensive exercise is contraindicated

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(3) CORRECT—increased histamine release related to the increased production of basophils results in generalized pruritus, a common discomfort

(4) because of increased viscosity, client is at risk for clotting formation, resulting in a CVA or an MI, but no need to measure vital signs unless client exhibits signs/symptoms of circulatory impairment

The home care LPN/LVN visits a client after discharge from a rehabilitation center. The client is diagnosed with head injury and is depressed because he has difficulty going out. The client cannot tolerate environmental stimuli, such as the noise in grocery stores and malls and at school activities. Which of the following interventions by the LPN/LVN is BEST?

• Suggest the client remain in his home until his noise tolerance improves.
• Contact the health care provider for a prescription for an antidepressant.
• Instruct the client to wear headphones with music playing when he goes out.

4. Recommend that the client seek psychotherapy. - ANSWER-Strategy:

Determine the outcome of each answer. Is it desired?

(1) need exposure to develop increased tolerance

(2) antidepressant may increase mood level but does not address the central problem

(3) CORRECT—decreases sensory input with some degree of exposure, allows client to participate in desired activities; head injuries cause clients to have decreased tolerance to sensory stimulation; can be managed with gradual exposure

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(4) does not have clinical depression; needs method to participate in desired activities

The LPN/LVN cares for a conscious client diagnosed with severe ketoacidosis.The LPN/LVN is MOST likely to administer which of the following?

• Orange juice.
• Peanut butter.
• Regular insulin.

4. NPH insulin. - ANSWER-Strategy: Think about each answer.

(1.) increases blood sugar; appropriate action for insulin reaction

(2.) commonly administered for hypoglycemia together with a natural glucose source to prevent rebound hypoglycemia

(3.) CORRECT— because regular insulin has a rapid onset and can be administered intravenously, it is the main therapeutic measure in the treatment of diabetic ketoacidosis

(4.) because NPH has an onset of 6 to 8 hours, it does not match the urgency of the client's need; even if it could be administered intravenously, the onset would not meet the needs of a client with severe ketoacidosis

The LPN/LVN cares for clients in the outpatient clinic. A client who had a bone marrow biopsy two days ago contacts the LPN/LVN for reassurance that he is caring for the aspiration site appropriately. The LPN/LVN should intervene if the client states which of the following?

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• "A warm bath feels good."
• "I am taking aspirin for the discomfort."
• "I walked one mile on the treadmill today."
• "I have increased my intake of fruits and fresh vegetables." - ANSWER-

Strategy: "Should intervene" indicates something is wrong.

(1) bone marrow biopsy performed to assess quality and quantity of each type of cell produced within the marrow; warm bath appropriate to decrease any discomfort

(2) CORRECT—slight risk of bleeding after procedure; aspirin alters platelet function and should not be used; can take acetaminophen

(3) no reason to intervene

(4) good health promotion habits; no reason to intervene The LPN/LVN cares for clients in the long-term care facility. Which of the following clients should the nurse see FIRST?

• A client diagnosed with irritable bowel syndrome complains of cramping and

loose stools

• A client diagnosed with a CVA complains of not having a bowel movement in 2

days.

• A client receiving digoxin (Lanoxin) complains of nausea and vomiting.
• A client with an indwelling Foley catheter asks to use the urinal. - ANSWER-

Strategy: Determine the most unstable client.

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