HESI EXIT..

PN EXIT EXAM 2020 PN EXIT EXAM 2020 1. At the end of a 12-hour shift the PN observes the urine in a client’s drainage. What action should the PN take next? Note the most recent white blood count 2. Thirty minutes after receiving IV morphine, a postoperative male client continue to rate his pain...what action should the PN implement first? Implement complementary pain relief methods 3. The PN is assisting a female client to obtain a voided specimen for uri. .meatus. Which intervention is performed next? Initiate the urine stream? 4. An 8-year old is placed in 90-90 traction for a fractured femur that resulted from. .further action by the PN? Weights are touching the foot of the bed 5. The PN is reviewing diet instructions with a female client who has hyper. .she has increased her intakes of protein and calories. What action should the PN take? Encourage the client to continue the dietary changes she has made 6. The PN reviews the procedure for measuring fluid intake and output glomerulonephritis and is Preparing for discharge from the hospital. What... -why the fluid measurements need to be recoded 7. The nurse is changing the dressing on a client’s wound. The nurse understands which of the following symptoms indicate a wound infection? Redness over 1 cm wide on per wound skin and tenderness 8. The nurse is developing a teaching plan for a client who is going home with a tracheostomy tube. Which of the following is the MOST important part of the teaching plan? The family of a client should know what to do in a case of emergency, i.e.: clogged tracheostomy tube and how to suction the client. 9. A 64-year-old male client comes to the provider’s office and complains of both legs hurting him when he walks a few blocks in his neighborhood. He states “When I sit down for a while, the pain eases off, but if I start walking a few blocks more, the pain comes back. The nurse recognizes this symptom may be related to peripheral vascular disease and is called what? Intermittent claudication 10. A narrowing and hardening of the arteries is called: Arteriosclerosis 11. A client has clusters of small vesicles over the thoracic region and describes severe pain and itching of the affected areas. Herpes zoster is diagnosed, and the client will be treated with which of these medications? Acyclovir (Zorivax) 12. When administrating oxygen to clients with conditions such as emphysema, it is important for the nurse to remember which one of the following facts as most important The drive to breathe may be dependent on low levels of oxygen in the blood 13. The nurse is preparing to instruct the client with pneumonia on managing the disease after discharge from the hospital. Which of the following is consistent with appropriate discharge planning for this client? Take all medications until they are finished, as ordered by MD 14. Immediately after sustaining severe burn wounds, the nurse would anticipate the client’s initial nutritional needs would usually be met by which of these methods? Total parenteral nutrition (TPN) 15. Which of the following measures should the nurse take when care for a client with TB in an acute care facility? Double-bag and dispose of client secretions as infectious waste 16. The most important nursing intervention for the nurse to remember in administrating Digoxin to a client is to? Take apical pule and withhold med is pulse is <60 17. The nurse is performing a respiratory assessment on a new client who has come to the clinic. On inspection of the anterior and posterior chest, she notices the symmetry of the chest is equal from front to back and from shoulder to shoulder like the shape of a barrel. The nurse knows the most common lung disease process causing this change in chest symmetry is? COPD 18. A nurse is reinforcing health teaching regarding skin cancer to a group of clients. Which of the following should the nurse identify as the leading cause of skin cancer? Sun exposure 19. Which of the following is potassium sparing diuretic? Aldactone 20. There are many types of wound dressings and therapies in evidence-based wound care. The wound vac has been around many years and is one of the best ways to heal a wound 60% faster than conventional dressings because? (select all that apply) -Negative pressure increases epithelial cell multiplications forming granulation tissue -Reduces edema in the wound and improves blood flow 21. A nurse is collecting data from a client who present to the provider’s office for evaluation pf multiple nevi. Which of the following findings should the nurse report to the provider as a possible sign of malignancy? Irregular borders 22. Which breath sounds are usually heard over the anterior third of the chest near the sternum and also scapular posteriorly, and have inspiration and expiration of equal duration? Bronchovesicular 23. Frank is a 4 year old paraplegic client with cerebral palsy who was admitted to the hospital with complications from the H1N1 virus. The nurse who was admitting him noted that he had an area of redness on his right malleolus that was non-blanchable. The nurse correctly identified this area as what stage of a pressure ulcer? Stage 1 24. A client has a prescription to discontinue intravenous therapy when the liter that is infusing at 150 mL per hour is...1200 the PN notes that there are 750 ml of solution remaining. At what time should the nurse expect to discontinue the intravenous therapy? 1700 25. The PN is caring for a client who had a total laryngectomy, left radical neck dissection...client is receiving nasogastric tube feedings via an internal pump. Today the rate of the feeding was increased. .ml/hr. What parameter should the PN use to evaluate the clients tolerate to the rate of the feeding? Gastric residual volumes 26. A new mother is breastfeeding her newborn for the first time after delivery and complains of nipple pain...Based on the client complaint, what action should the PN take? Ensure that all the areolar tissue of the nipple is in the infants’ mouth. 27. Which site should the PN use when administering an injection of Rho (D) Immune negative postpartum client? Deltoid 28. A client begins an antidepressant drug during the second day of hospitalization. Which assessment is most important for the LPN/LVN to include in this client's plan of care while the client is taking the antidepressant? Mood 29. Based on the documentation in the medical record, which action should the LPN/LVN implement next? Give the rubella vaccine subcutaneously 30. A client is admitted to the hospital with a diagnosis of Pneumonia. Which intervention should the LPN/LVN implement to prevent complications associated with Pneumonia? Encourage mobilization and ambulation 31. Which nursing activity is within the scope of practice for the practical nurse? Observe a client rotate the subcutaneous site for an insulin pump 32. After morning dressing changes are completed, a male client who has paraplegia contaminates his ischial decubiti dressing with a diarrheal stool. What activity is best for the nurse to assign to the unlicensed assistive personnel? Provide perianal care and collect clean linens for the dressing change 33. Which ethnic group aged 45-74 has a higher chance of coronary artery disease than men and women in the same age group? African American 34. There are certain risk factors associated with cardiovascular disease. Which of these would be considered an alterable risk factor? Physical activity 35. A severe potential surgical complication from an aortic aneurysm repair is? Hemorrhage 36. Every in-patient facility should have a type of scoring tool for nurses to assess their clients for risk of pressure ulcers. One of the most common and research-based tools currently used is called what? Braden Scale 37. A nurse is conducting a health and wellness seminar for a local community center. Cardiac care is the topic and the nurse is reviewing different types of cardiac infections including endocarditis. Which of the following puts the client most at risk for endocarditis? Dental caries 38. Increasing the protein vitamin C, and iron in the diet will enhance tissue regeneration. Which one of the following food combinations would the nurse recommend to a client to assist healing of a venous stasis ulcer? Roast beef and spinach salad 39. A client is admitted to the hospital. The nurse needs to document the client’s weight in kilograms. The client weighs 156 pounds. How many kilograms does the client weigh? 70.9kg 40. While inserting an indwelling urinary catheter into a female client the catheter slips into the clients’ vagina. What would the PN do? Keep the catheter in the vagina and insert a new catheter through the urethral meatus 41. Six hours after removing a client’s indwelling urinary catheter the client has not voided ad is expressing discomfort from a distended bladder. What action would the PN take? Obtain an order for intermittent urinary catheterization 42. During a health history the PN learns that an older client had the chickenpox virus as a child. Which immunization would be indicated for the client at this time? Vaccination for shingles 43. The PN is reviewing the state nurse practice act. What information will be included within the document? Legal requirements for PN 44. The LPN/LVN is assessing an older resident of a long-term care facility who has a history of Benign Prostatic Hypertrophy and identifies that the client's bladder is distended. The healthcare provider prescribes post-voided residual catheterization over the next 24 hours and placement of an indwelling catheter if the residual volume exceeds 100 mL. The client's PO intake is 600 mL, and fifteen minutes ago, the client voided 90 mL. What action should the nurse take? Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL. Inflate the balloon. 45. A client is receiving dexamethasone (Hexadrol, Decadron). What symptoms should the nurse recognize as Cushionoid side effects? Moon face, Slow wound healing, muscle wasting sodium and water retention 46. The cervix is the opening into the uterine cavity. What is its function in reproduction? Secretes mucus to facilitate sperm transport 47. The LPN/LVN is working in a community health setting and assisting the charge nurse in performing health screenings. Which individual is at highest risk for contracting an HIV infection? 17-year-old who is sexually active simultaneously with numerous partners 48. The LPN/LVN is administering amiodarone (Cordarone) to a client who has been admitted with Atrial Fibrillation (AFIB). What therapeutic response should the nurse anticipate? Conversion of irregular heart rate to regular heart rhythm 49. An elderly male client is planning to vacation with a group of senior citizens. He is concerned about developing constipation during the airplane flight. He share this concern with the nurse at the retirement home. Which recommendation is best for the nurse to provide? Increase the fluid intake in your diet 50. The LPN/LVN is assessing a client with dark skin who is in Respiratory Distress. Which client response should the nurse evaluate to determine cyanosis in this particular client? The lips and mucus membranes of a client with dark skin are dusky in color 51. When inserting an indwelling urinary catheter (Foley) in a female client, the nurse observes during flow into the tubing. What action is taken next? Insert the catheter an additional inch 52. A client has a prescription for a Transcutaneous Electrical Nerve Stimulator (TENS) unit for pain management during the postoperative period following a lumber Laminectomy. What information should the nurse reinforce about the action of this adjuvant pain modality? Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus 53. Based on the Nursing diagnosis of "Potential for infection related to second and third degree burns," which intervention has the highest priority? Use of careful hand washing technique 54. A client is diagnosed with respiratory acidosis. What blood pH value will the PN assess when reviewing the clients arterial blood gas results? 7.29 55. A 16 year old client is preceded to receive 1.0 mL of an intramuscular injection. Which sites would the PN consider to administer this medication? Deltoid 56. The PN provides cold packs to the perineum of a postpartum client with perineal hematoma. What will the PN do to evaluate the effectiveness of this action? Observe the hematoma for changes in size 57. A client has sustained a burn affecting the clients’ adipose tissue and blood vessels. Which layer of the clients’ skin has been affected by the burn? Subcutaneous layer 58. During the assessment go a school age child the PN determines that the client is in Erickson’s developmental stage of industry vs inferiority. Which behavior did the client demonstrate? Sitting quietly reading a book 59. A client with irritable bowel syndrome is receiving dicyclomine an anticholinergic drug? Provide oral care 60. The PN is caring for a client in buck’s tract what is the priority goal for the client in traction? Maintain straight body alignment 61. Client with Hungtingtons disease starts jerking around while the family is there what should the PN do? Offer emotional support to the family 62. A client with small bowel obstruction is experiencing frequent vomiting which instructions are most important for the PN to provide to the UAP who is completing morning care for this client? Measure all emesis accurately 63. Single mother of a child with head injury comes crying to the clinic what should the PN tell her? This must seem overwhelming to you right now 64. On admission to the medical unit a client who is homeless and has a history of HIV with persistent cough? Erythema and indurations of 5mm at site 65. When preparing to administer medications to an older resident the PN notices that several medications that were supposed to be administered during the previous shift have not been entered as given in the computer. What action should the PN take? Contact the medication nurse to clarify the findings 66. Which picture of nailbeds indicate hypoxia? Choose the one that has a bump right below the nail bed 67. The LPN/LVN is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding? The infusion site is infiltrated 68. The LPN/LVN observes that a male client's urinary catheter (Foley) drainage tubing is secured with tape to his abdomen and then attached to the bed frame. What action should the nurse implement? Observe the appearance of the urine in the drainage tubing 69. In assisting a client to obtain a sputum specimen, the LPN/LVN observes the client cough and spit a large amount of frothy saliva in the specimen collection cup. What action should the nurse implement next? Re-instruct the client in coughing techniques to obtain another specimen 70. After report, the LPN/LVN receives the laboratory values for 4 clients. Which client requires the nurse's immediate intervention? The client who is..... Trembling and has a glucose level of 50 mg/dL 71. 4 hours after administration of 20U of regular insulin, the client becomes shaky and diaphoretic. What action should the nurse take? Give the client crackers and milk 72. The LPN/LVN is changing the colostomy bag for a client who is complaining of leakage of diarrheal stool under the disposable ostomy bag. What action should the nurse implement to prevent leakage? Cut the bag opening to the measurement of the stoma size 73. Prior to administering morphine sulfate (Morphine), the LPN/LVN takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified? A respiratory rate of 10 breaths per minute 74. Following an open reduction of the tibian, the LPN/LVN notes fresh bleeding on the client's cast. Which intervention should the nurse implement? Outline the area with ink and check it q15 minutes to see if the area has increased 75. The LPN is with a client when the healthcare provider explains that the biopsy classifies the results as a T1N0M0 tumor. Later in the morning, the client asks the nurse, "What do these letters T1N0M0, stand for?" which response should the nurse provide first? "The letters stand for tumor size, node involvement and metastasis." 76. The LPN/LVN plans to administer the rubella vaccine to a postpartum client whose titer is < 1:8 and who is breastfeeding? What information should the nurse provide this client? The vaccine is given to produce maternal antibodies before lactation occurs 77. In counting a client's radial pulse, the LPN/LVN notes the pulse is weak and irregular. To record the most accurate heart rate, what should the nurse take? Count the apical pulse rate for sixty seconds 78. Which structures are located in the subcutaneous layer of the skin? Adipose cells and blood vessels 79. The LPN/LVN in charge of a Nursing unit in a long term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients? Cleanse the perineal area of a client with urinary incontinence 80. A client requires application of an eye shield to the right eye. What should the nurse do in order to apply tape in which direction to anchor the shield most effectively? Longitudinally from the right forehead to the right cheek 81. 36 hours after delivery, the nurse determines a client's fundus is just above the umbilicus and displaced to the right of midline. What action should the nurse take first? Palpate the bladder for distention 82. A client presents in the clinic because of generalized swelling after a bee sting. What intervention should the nurse implement first? Determine respiratory status and apply a pulse oximeter 83. The LPN/LVN is administering multiple medications to a 78-year-old client because of problems related to polypharmacy. At this client's age, which assessment is most important for the nurse to make? Cumulative serum drug levels and toxicity 84. In obtaining an orthostatic vital sign measurement, what action should the nurse take first? Instruct the client to lie supine 85. A 3-week-old infant is admitted for surgical repair of Pyloric Stenosis. What interventions should the nurse expect to implement to establish hydration in the immediate postoperative period? Nipple feedings with glucose water 86. Urinary catheter (Foley) with a 5mL inflated balloon is being removed by the nurse. After withdrawing 5 mL of fluid from the balloon, the nurse begins to withdraw the catheter while the client is in a Semi-Fowler's position. However, the nurse meets resistance and the clients’ voices discomfort. What action should the nurse take next? Assist the client in taking a series of deep breaths 87. During morning report the PN learns that an assigned client has phlebitis from a intravenous access device. What will the PN observe in this client? Redness, warmth, and edema of the site 88. The PN is caring for a client with atrial fibrillation. What would be an expected finding when assessing this client? Heart rate 88 and irregular 89. A client’s blood pressure is unusually elevated. Which factors would contribute to this client’s blood pressure elevation? Stress 90. To obtain an estimate of a client’s systolic blood pressure, what action should the PN take first? Palpate the client’s brachial pulse 91. A client reports feeling numbness and tingling in extremities. What action should the PN implement? Review the client’s serum electrolyte levels 92. Immediately after birth, which nursing intervention has the highest priority for the newborn infant? Preventing heat loss and neonatal cold stress 93. A 0800 a client’s apical pulse rate is 98 beats/minute> Four hours later the apical pulse rate is 54 beats/minute. What action should the PN take next? Determine the level of consciousness 94. Which client information is most important for the PN to consider when providing instructions to the UAP about providing morning care to a postoperative client? Urinary output of 50 mL/hour 95. After report, the PN receives the laboratory values for four clients. Which client requires the PNs immediate intervention? A client who is trembling and has a glucose level of 50 96. During recovery after the delivery of a normal infant a client is receiving...ringers 1000 mL with oxytocin 20 units. The PN should evaluate the client for which therapeutic response? Stimulation of uterine contractions 97. A 5-year old child is admitted with full thickness burns over 30% of the total body surface areas (TBSA). After fluid replacement therapy is initiated, which finding should the PN use to evaluate the effectiveness of the therapy? Urine output 98. The PN enters the room of a client who is disoriented and has a wrist restraint secured as seen in the picture what action should the PN take? Photo is of hospital bed and restraint is on the bed frame in a bow tie use a full knot to secure the restraint line 99. A LPN/LVN is contributing to a care plan for an adolescent female client with Anorexia Nervosa. Which outcome statement or goal would be most appropriate for this client? She will develop a positive body image and self- identity 100. A female client with no family history of Breast Cancer (BA) asks the nurse how often she should obtain a Mammogram. Which additional client information should the nurse obtain before answering this client's question? Breastfeeding history 101. The LPN/LVN is working on the postpartum unit and is assisting a new mother with her newborn's diaper change. The mother states that the infant fed well and completed the whole bottle of formula. What action should the nurse implement first when the infant begins to spit up during the diaper change? Turn the newborn and bulb suction the mouth and nose 102. An older male client tells the nurse that his religion does not permit him to bathe daily. How should the nurse respond? Request that the client clarify his religious beliefs about bathing 103. A new father asks the nurse the reason for placing an ophthalmic ointment in his newborn's eyes. What information should the PN provide? State law mandates all newborns receive prophylactic treatment to prevent gonorrheal or chlamydial ophthalmic infection 104. The scope of practice for the practical nurse includes which client assessments? Transfer of a client with sepsis from a long-term care facility 105. What skin care measure should the nurse implement for a client who underwent an external radiation treatment the previous day? Cleanse the radiated area with water and pat the skin dry 106. Which organ lays retroperitoeally? Kidneys 107. The LPN/LVN is caring for a client with Myasthenia Gravis. What time of day is best for the nurse to schedule physical exercises with the physical therapy department? After breakfast 108. The LPN/LVN is planning to ambulate client who has been on bed rest for 24 hours following a Colon Resection. To ambulate this client safely, which intervention should the nurse implement first? Assist the client to a bedside sitting position 109. A Client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture? The neck extended backward using a rolled towel behind the neck 110. A client receives a new prescription for the angiotensin II receptor antagonist losartan (Cozaar). Which client instruction should the nurse encourage this client to follow? Move slowly when getting up to prevent sudden dizziness 111. The healthcare provider prescribes erythromycin (ilosone) 300 mg PO QID. The medication label reads, "ilosone 100mg/5mL" How many mL should the nurse administer at each does? (Enter the numeric value only) 15 112. The LPN/LVN is monitoring a client with an IV infusion in the left antecubital fossae. The infusion pump is functioning without alarms at the prescribed rate of 100mL/hour. The site is warm, red and without swelling. What conclusion should these findings indicate to the nurse? The site is inflamed and should be reported to the RN for placement in another site. 113. The LPN/LVN reviews the laboratory results of a client whose serum pH is 7.38 on the pH scale what does this value imply about the clients homeostasis Normal serum PH 114. The LPN/LVN plans to assess a newborn and to check the infant's Moro reflex. In assessing this reflex, the nurse is evaluating which parameter? Neurological integrity 115. The LPN/LVN assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspirations. To ensure that the task is safely delegated what action should the nurse implement? Observe the UAP's ability to implement precautions during feed 116. The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take? Ask the client why the bath was refused 117. Following discharge teaching, a male client with duodenal ulcer tells the nurse the he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow- up action by the nurse? Review with the client the need to avoid foods that are rich in milk and cream 118. An adolescent male with severe acne recently started treatment with isotretinoin, a form of Vitamin A. During a follow up clinic appointment, which assessment is most important for the PN to complete? Ask about occurrence and frequency of nosebleeds 119. The PN is caring for a client who has silvery scaling plaques bilaterally on elbows, forearms, and palms. When scratched, the skin bleeds over these plaques. What is most important to reinforce in this clients plan of care? Interventions to decrease emotional stress 120. An adult client is undergoing weekly external radiation treatments for breast cancer. Upon arrival at the outpatient clinic for a scheduled treatment, the client reports increasing fatigue to the PN, who is taking the client the clients’ vital signs. What action should the PN implement? Reinforce the need for extra rest periods and plenty of sleep 121. The PN is completing a focused assessment of a client with acute hepatitis A. The client reports a constant sense of fatigue. How should the PN respond? Affirm the importance of rest to promote liver healing 122. When the PN plans daily care for a group pf clients, which client should the PN see first due to the risk of complication?` An older client with a stroke who is febrile and confused 123. Which foot care instructions is most important for the PN to reinforce that minimizes a Long term complication for a client who is newly diagnosed with type 2 diabetes mellitus (DM)? Report any food injury or sore that does not readily heal 124. During a clinic visit for a sore throat a client’s basal metabolic panel reveals a serum potassium of 3.0bmL q/L. Which action should the PN recommend to the client based on this finding? Increase intake of dried peaches and apricots 125. A client with a fractured left hip fracture is in Bucks's traction. The PN should expect the client to exhibit which outcome? The left foot is warm to touch with a palpable dorsal pedis pulse 126. When entering the room of an older female resident of a long term care facility, the PN finds one of the male residents in bed with her. What action should the PN take? Close the door and report the finding to the charge nurse 127. The LPN/LVN assesses the perineum of a client 12 hours after a normal vaginal delivery and finds that she has Perineal Hematomas. The nurse should prepare for which treatment? Cold packs to the perineum 128. A client at 28 weeks gestation is admitted to the antepartum unit and is being treated for preterm labor. She has a prescription for brethine (Terbutaline) 250 micrograms subcutaneously q4h. The medication is available for injection in 1 mg per ML vials. How many mL should the nurse administer? 0.25 129. A school-aged child with AIDS is exposed to an active case of Varicella. The nurse should recommend that the family take which action? Obtain the varicella zoster immune globulin 130. The principle of client advocacy is best demonstrated when the nurse exhibits which behaviors on behalf of the client? Nurse who translates complaints for a Spanish- speaking client to the healthcare provider during rounds 131. The LPN/LVN is preparing a client for an Intravenous Pyelogram (IVP) scheduled for the following morning. What action is most important for the nurse to implement? Determine if the client has any allergies to shellfish 132. A LPN/LVN refuses to perform a procedure because it is beyond the scope of practice for practical nurses. Which resource best defines the nurse's legal responsibility in regard to scope of practice? State nurse Practice Act 133. While making the bed of a female client who is sitting in the bedside chair, the nurse observes the client seem anxious. To encourage verbalization by the client, what action should the nurse take? Sit next to the client at a slight angle to continue the conversation 134. A client is admitted for observation after experiencing a Transient Ischemic Attack (TIA). The nurse anticipates implementing care for which client problem? Altered breathing patterns 135. An elderly postoperative client has the Nursing diagnosis, "Impaired mobility related to fear of falling." Which desired outcome best directs Nursing actions for this client? The client will ambulate with assistance q4h 136. A female client complains to the nurse about being admitted to a semi- private room and expresses her displeasure because she requested a private room prior to admission. What response is best for the nurse to provide this client? Your healthcare provider must provide a written request to get you a private room 137. During preoperative preparation, the nurse should offer the client which explanation about why deep breathing exercising with an incentive spirometer are necessary after surgery? "Deep breathing exercises using spirometer will help prevent postoperative complications." 138. The LPN/LVN is caring for a client who had a total Laryngectomy, Left Radical Neck Dissection, and tracheostomy. The client is receiving Nasogastric (NG) tube feedings via an enteral pump. Today the rate of the feeding was increased from 50mL/hr to 75mL/hr. What parameter should the nurse evaluate the client's tolerance to the rate of feeding? Gastric residual volumes 139. A client is admitted with a fever of undermined origin (FUO). During rounds, the nurse finds the client diaphoretic, and the linens are damp. What should the nurse do first? Check the client's vital signs and pain scale 140. Which client should the nurse assign to an unlicensed assistive personnel (UAP)? A client who has regular heart rate and after a pacemaker replacement now needs to ambulate 141. The LPN/LVN is administering the shingles vaccine to an older male- client who asks why he should receive the immunization. Which information should the nurse provide? A history of chickenpox indicates that the harbors the dormant virus 142. In preparing a client for a lumbar puncture, what action should the nurse implement? Teach the client to cough and deep breathing exercises 143. A client who had a lobectomy two days ago has 2 chest tubes, each attached to a water-sealed drainage system, Pleur-Evac. The nurse observes that in the last 8 hours the serosanguineous fluid has diminished to output in the drainage chamber. What is the most likely outcome of this observation? Change the Pleur-Evac system and re-assess output in the empty chamber 144. While caring for a client who has been vomiting, the nurse notes that the client's breath has developed a fruity odor. What assessment should the nurse perform first? Determine the client's capillary glucose 145. The LPN/LVN is preparing to assist an elderly client to the bathroom. The nurse knows that an elderly adult's center of gravity changes from the hips to another area of the body. Which area of the body is the center of gravity for the elderly client? Upper torso 146. A 60 year-old client with cancer of the liver is in Hepatic Coma and unresponsive. What should the nurse say to family members who are inquiring about the condition of their loved one? "Your loved one's condition is very critical, and there has been no response in the last 24 hours" 147. A client complains of kidney pain. The nurse understands that the kidneys are located where? On the retroperitoneal posterior abdominal wall at the costovertebral angle 148. The LPN/LVN receives report on an adult client who has a central intravenous (IV) infusion. Where should the nurse observe when assessing the integrity of the access site? Chest wall below the clavicle 149. The healthcare provider prescribes an IV solution of clindamycin (Cleocin) 850mg in 75 mL of D2W to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many gtt/ minute? (Enter numeric value only. if rounding is required round to the nearest whole number) 75mL X 15gtt/mL = 38 Correct Answer: 38 150. The LPN/LVN is administering a subcutaneous injection of epoetin (Epogen) to a client with Chronic Kidney Disease (CKD). This medication is being administered to treat which manifestation of CKD? Anemia 151. The LPN/LVN is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. Prior to administering medications to this resident, what is the best Nursing action? Ask a regular staff member to confirm the residents’ identity 152. The LPN/LVN is assessing an older male client with Gastritis. He has been unable to eat for the past 48 hours and has been vomiting during this same period of time. Which finding can the nurse expect this client to exhibit? Dry skin and an increased heart rate 153. Which client information is most important for the PN to consider when providing instructions to the UAP about providing morning care to a postoperative client? Urinary output of 50 mL/hour 154. After report, the PN receives the laboratory values for four clients. Which client requires the PNs immediate intervention? A client who is trembling and has a glucose level of 50 155. During recovery after the delivery of a normal infant a client is receiving...ringers 1000 mL with oxytocin 20 units. The PN should evaluate the client for which therapeutic response? Stimulation of uterine contractions 156. A 5-year old child is admitted with full thickness burns over 30% of the total body surface areas (TBSA). After fluid replacement therapy is initiated, which finding should the PN use to evaluate the effectiveness of the therapy? Urine output 157. The PN enters the room of a client who is disoriented and has a wrist restraint secured as seen in the picture what action should the PN take? Photo is of hospital bed and restraint Is on the bed frame in a bow tie use a full knot to secure the restraint line 158. A new mother asks the PN about an area of swelling on her baby head that lies across the suture line near the posterior fontanel. How should the PN respond? Caput succedaneum will be absorbed and causes no problem 159. The PN obtains a finger stick glucose for a client with type 1 diabetes mellitus who is conscious and demonstrating hand tremors and shaking. The PN reports the clients result of 55 mg/dL to the nurse. What action should the PN implement next? Provide the client with a glass of milk and crackers 160. A client who is prim gravida at term comes to the prenatal clinic and tells the PN that she is having contractions every 5 minutes. The PN monitors the client for 1 hour using a external fetal monitor and determines that the clients contractions are 7 to 15 minutes apart lasting 20- 30 seconds with mild intensity by palpation. What action should the PN take? Send the client home and instruct her to call the clinic when her contractions are 5 minutes apart for one hour 161. The PN plans to evaluate an adult’s response to a prescription for colchicine. Last week the client was seen in the clinic for pain in the great left toe, which was the result of an acute attack of gout. Which data should the PN obtain to evaluate the therapeutic effectiveness of this medication? Pain scale level during walking 162. The PN is caring for a client who was recently diagnosed with hepatitis B virus (HBV). The PN observes that the client’s urine is the color of dark tea. What action should the PN take? Encourage increased oral fluid intake 163. A client develops generalized edema associated with chronic kidney disease (CKD). The PN understands the formation of the edema is the result of which physiological process? Plasma protein losses resulting in decreased oncotic pressure within the vessels 164. The PN and UAP are providing care for a client who exhibits signs of neglect syndrome following a stroke affecting the right hemisphere. What action should the PN implement? Demonstrate to the UAP how to approach the client from the clients left side 165. When assessing an adult male who present at the community health clinic with a history of hypertension the nurse notes that he has 2+ pitting edema in both ankles. He also has a history of gastroesophogeal reflux disease and depression. Which interventions is most important for the PN to implement? Review the clients use of over the counter (OTC) medications 166. A client with Alzheimers disease (AD) is receiving trazadone (Desyrel) a recently prescribed atypical antidepressant. The caregiver tells the home health nurse that the clients’ mood and sleep patterns are improved but there is no change in cognitive ability. How should the nurse respond to this information? Confirm that the desired effect of the medication has been achieved? 167. A client on bed rest refuses to wear the prescribed pneumatic compression device after surgery, what action should the PN implement in response to the clients refusal? Emphasize the importance of active foot flexion 168. A client recovering from a stroke is learning how to use a cane. How should it be placed? On the stronger side of the body 169. An elderly female client tells the nurse that she does not do regular Breast Self- Examinations (BSE) because she is too old. The nurse's response to the client is based on what information? The incidence of breast cancer increases with age 170. A client with Meningitis is in a coma and Nursing care includes seizure precautions. To help prevent seizure activity, what interventions should the nurse implement? Maintain a quiet calm darkened environment 171. The LPN/LVN is assisting a female client to obtain a voided specimen for urine culture. After the client cleanses the meatus, which intervention is performed next? Separate the labia 172. A new protocol for fall prevention is being implemented on the medical unit. During safety rounds, the nurse identifies that an unlicensed assistive personnel (UAP) has omitted a vital component of the protocol. After implementing the missing component, what should action should the nurse take? Supervise the UAP after reviewing the protocol 173. What is the best intervention for the nurse to implement when providing morning care for an ambulatory client with an indwelling catheter (Foley)? Keep the catheter intact while assisting the client with a shower 174. The scope of practice for the practical nurse includes which client assessments? Transfer of a client with sepsis from a long-term care facility 175. What skin care measure should the nurse implement for a client who underwent an external radiation treatment the previous day? Cleanse the radiated area with water and pat the skin dry 176. A 26-year-old gravida 4, para 0 had a spontaneous abortion at 9 weeks gestation. At one-house post dilation and curettage (D&C) the LPN/LVN assess the vital signs and vaginal bleeding. The client begins to cry softly. How should the nurse intervene? Express sorrow for the client's grief and offer to sit with her 177. A terminally ill male client and his family are requesting hospice care after discharge from the hospital and ask the LPN/LVN to explain what kind of care they should expect. The nurse should indicate that hospice philosophy focuses on what aspect of health care? Enhance symptom management to improve end of life quality 178. The LPN/LVN observes a wife shaving her husband's beard with a safety razor by holding the skin taut and shaving in the direction of the hair growth. What action should the nurse take? Encourage the wife to continue shaving her husband 179. To assess pedal pulse what arterial sites should the nurse palpate? (select all that apply) Posterior tibialis artery, Dorsalis pedis artery 180. The LPN/LVN is admitting a client who is diagnosed with Angina Pectoris. Which precipitating factor in this client's history is likely to be related to the anginal pain? Smokes one pack of cigarettes daily