LVN NCLEX 5 EXAM QUESTIONS WITH
ACCURATE ANSWERS RATED A+
The nurse is teaching a group of client-care attendants about infection-control
measures. The nurse tells the group that the first line of intervention for
preventing the spread of infection is: - ANSWER Washing hands
A nurse monitors members of the healthcare team for the use of interventions to
reduce the occurrence of methicillin-resistant staphylococcus aureus (MRSA)
and other nosocomial infections. Which finding demonstrates to the nurse that
the team members understand infection control measures? - ANSWER
Performing hand hygiene before and after contact with every client
A nurse is providing care to a client after surgery. The nurse must practice
surgical asepsis when performing which procedure? - ANSWER Insertion of an
indwelling urinary catheter
Which nursing action is appropriate when performing wound care for a client
who has a diabetic foot ulcer? - ANSWER Change the sterile field after sterile
water is spilled on it
After completing a course on infection control, a licensed practical nurse (LPN)
demonstrates knowledge of the use of standard precautions based on which
statement? - ANSWER Standard precautions are mandatory for use with all
client care.
A nurse implements standard precautions when caring for a client. Which action
best demonstrates proper use of these precautions? - ANSWER Performing
hand hygiene immediately after removing gloves
A nurse is implementing standard precautions when caring for all assigned
clients, regardless of their diagnosis or infection status. The nurse
demonstrates adherence to the guidelines for standard precautions by which
action? - ANSWER disposing of sharps into a puncture-resistant container
The nurse is aware that Standard Precautions represent the first tier of Centers
for Disease Control guidelines for isolation precautions. Which is the nurse's
primary responsibility when following Standard Precautions? - ANSWER
Consider all body substances potentially infectious
,The nurse educator is presenting information about Standard Precautions to a
group of newly hired nurses. Hand hygiene is a necessity in Standard
Precautions. Which true statement about hand washing would the educator
include in her teachings? - ANSWER Frequent hand washing reduces
transmission of pathogens from one client to another.
Which procedure performed by the nurse will require the use of sterile
technique? - ANSWER inserting an indwelling urinary catheter
The health care provider orders contact precautions for a client with a draining
wound. Which action should the nurse take to initiate these precautions? -
ANSWER place an isolation cart containing gloves and gowns outside the
client's room.
A nurse is reviewing infection-control measures with a group of unlicensed
assistive personnel (UAP). Which statement made by one of the group members
indicates learning goals have been met? - ANSWER Standard precautions
should be used when performing client care.
A certified nursing assistant (CNA) is caring for a client with Clostridium difficile
diarrhea and asks the nurse, "How can I keep from catching this from the
client?" The nurse reminds the CNA to wash her hands and to ensure that the
client is placed: - ANSWER on contact isolation
A nurse is changing a client's dressing and providing wound care. Which activity
should the nurse perform first? - ANSWER wash hands thoroughly
A client is admitted to the health care facility with active tuberculosis (TB). The
nurse should include which intervention in the plan of care? - ANSWER Putting
on an individually fitted N95 respiratory or high-efficiency particulate air (HEPA)
respirator when entering the client's room
A nurse must obtain the blood pressure of a client in airborne isolation. Which
method is best to prevent transmission of infection to other clients by the
equipment? - ANSWER Leave the equipment in the room for use only with that
client
The nurse is teaching a group of unlicensed assistive personnel (UAP) about
standard precautions. What information should the nurse include that best
describes standard precautions? Select all that apply. - ANSWER >Wear gloves
when there is the potential for contact with a clientj's body fluid; >Wear gloves, a
face shield, and a gown when contact with body fluids is possible
The nurse preceptor is discussing Standard Precautions with a graduate nurse.
The preceptor should include which measures when discussing Standard
,Precautions? Select all that apply. - ANSWER >wear gloves when administering
intramuscular (IM) medication
>wash hands after removal of gloves
The physician orders contact precautions for a client with a draining wound.
Which action should the nurse take to initiate these precautions? - ANSWER
Place an isolation cart containing gloves and gowns outside the client's room.
A nurse is working at a local emergency department. A nearby building
explosion has occurred, and many of the victims involved are being brought to
the facility. Which client would the nurse expect to be triaged first? - ANSWER a
62-year-old with tachypnea
The nurse complies with a client's request to administer his medication at 9 p.m.
instead of 10 p.m. so he can go to sleep earlier. Which type of nursing
intervention is the nurse utilizing? - ANSWER independent
The charge nurse is making client care assignments. Which client is most
appropriate for a licensed practical nurse? - ANSWER A stable 6-month-old
infant with pneumonia
A clinical pathway is guiding care for a postpartum client who had an
uncomplicated vaginal delivery of an 8-lb, 2-oz (3,686-g) baby 24 hours ago. The
client has no episiotomy and is bottle-feeding her baby. Which outcome should
be achieved within the next 8 hours? - ANSWER Client will demonstrate ability to
bottle-feed the neonate.
A 33-year-old client who tested positive for the human immunodeficiency virus
(HIV) is admitted to the medical unit with pancreatitis. A nurse director from
another unit comes into the medical unit nurses' station and begins reading the
client's chart. The staff nurse questions the director, who says that the client is
her neighbor's son. What should the nurse do to protect the client's right to
privacy? - ANSWER Inform the nurse director that she's violating the client's
right to privacy and ask her to return the chart.
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver
oxygen to compromised tissues. Which condition would benefit from hyperbaric
oxygen therapy? - ANSWER compromised skin graft
After a physician explains the risks and benefits of a clinical trial to a client, the
client agrees to participate. Later that day, the client requests clarification of
the process involved in the clinical trial. As a member of the multidisciplinary
team, how should the nurse respond? - ANSWER Provide the information
requested
, A 75-year-old client who was admitted to the hospital with a stroke informs the
nurse that he doesn't want to be kept alive with machines. He wants to make
sure that everyone knows his wishes. Which action should the nurse take? -
ANSWER Make arrangements for the client to receive information about
advance directives
After undergoing a right lower lobectomy for treatment of lung cancer, a 75-
year-old client returns to his room with a chest tube in place. Several hours later
a nurse finds the client out of bed barely able to speak, with the chest tube
removed. Which action should the nurse take immediately? - ANSWER Cover the
insertion site with an occlusive dressing, call for assistance, and remain with the
client.
A client with end-stage pulmonary hypertension tells his physician that he
doesn't want any heroic measures should his heart stop and that he doesn't
want to be placed on a ventilator. The physician enters a do-not-resuscitate
order into the hospital's computer system. Which ethical principle is a nurse
upholding by supporting the client's decision? - ANSWER Autonomy
A nurse is working with the team to develop a neonate's plan of care. Which
action would be the highest priority in regulating the neonate's temperature? -
ANSWER Block sources of radiant, convective, conductive, and evaporative
losses.
The nurse, who is providing care for four clients, receives a report on the
clients. Which report is an outcome indicator? - ANSWER pain level 3/10 one
hour after administration of pain medication
Which finding is common when gathering data from a child with a total
anomalous pulmonary venous return defect? - ANSWER frequent respiratory
infections
A nurse is caring for a client who received pain medication before leaving the
post anesthesia care unit (PACU). Upon returning to the room, the client reports
pain and requests more pain medication. Which action is most appropriate for
the nurse to take? - ANSWER Obtain the client's vital signs.
The nurse suspects that a client is not swallowing the administered dose of an
anxiolytic medication and is concerned that the client may be disposing of it in
the trash. Which action should the nurse take first? - ANSWER Talk with the
client about the concerns.
A nurse is caring for a client who had abdominal surgery 3 days ago. The client
states, "I haven't moved my bowels, but I am passing gas." What nursing action
is appropriate for this client? - ANSWER Encourage the client to ambulate.
ACCURATE ANSWERS RATED A+
The nurse is teaching a group of client-care attendants about infection-control
measures. The nurse tells the group that the first line of intervention for
preventing the spread of infection is: - ANSWER Washing hands
A nurse monitors members of the healthcare team for the use of interventions to
reduce the occurrence of methicillin-resistant staphylococcus aureus (MRSA)
and other nosocomial infections. Which finding demonstrates to the nurse that
the team members understand infection control measures? - ANSWER
Performing hand hygiene before and after contact with every client
A nurse is providing care to a client after surgery. The nurse must practice
surgical asepsis when performing which procedure? - ANSWER Insertion of an
indwelling urinary catheter
Which nursing action is appropriate when performing wound care for a client
who has a diabetic foot ulcer? - ANSWER Change the sterile field after sterile
water is spilled on it
After completing a course on infection control, a licensed practical nurse (LPN)
demonstrates knowledge of the use of standard precautions based on which
statement? - ANSWER Standard precautions are mandatory for use with all
client care.
A nurse implements standard precautions when caring for a client. Which action
best demonstrates proper use of these precautions? - ANSWER Performing
hand hygiene immediately after removing gloves
A nurse is implementing standard precautions when caring for all assigned
clients, regardless of their diagnosis or infection status. The nurse
demonstrates adherence to the guidelines for standard precautions by which
action? - ANSWER disposing of sharps into a puncture-resistant container
The nurse is aware that Standard Precautions represent the first tier of Centers
for Disease Control guidelines for isolation precautions. Which is the nurse's
primary responsibility when following Standard Precautions? - ANSWER
Consider all body substances potentially infectious
,The nurse educator is presenting information about Standard Precautions to a
group of newly hired nurses. Hand hygiene is a necessity in Standard
Precautions. Which true statement about hand washing would the educator
include in her teachings? - ANSWER Frequent hand washing reduces
transmission of pathogens from one client to another.
Which procedure performed by the nurse will require the use of sterile
technique? - ANSWER inserting an indwelling urinary catheter
The health care provider orders contact precautions for a client with a draining
wound. Which action should the nurse take to initiate these precautions? -
ANSWER place an isolation cart containing gloves and gowns outside the
client's room.
A nurse is reviewing infection-control measures with a group of unlicensed
assistive personnel (UAP). Which statement made by one of the group members
indicates learning goals have been met? - ANSWER Standard precautions
should be used when performing client care.
A certified nursing assistant (CNA) is caring for a client with Clostridium difficile
diarrhea and asks the nurse, "How can I keep from catching this from the
client?" The nurse reminds the CNA to wash her hands and to ensure that the
client is placed: - ANSWER on contact isolation
A nurse is changing a client's dressing and providing wound care. Which activity
should the nurse perform first? - ANSWER wash hands thoroughly
A client is admitted to the health care facility with active tuberculosis (TB). The
nurse should include which intervention in the plan of care? - ANSWER Putting
on an individually fitted N95 respiratory or high-efficiency particulate air (HEPA)
respirator when entering the client's room
A nurse must obtain the blood pressure of a client in airborne isolation. Which
method is best to prevent transmission of infection to other clients by the
equipment? - ANSWER Leave the equipment in the room for use only with that
client
The nurse is teaching a group of unlicensed assistive personnel (UAP) about
standard precautions. What information should the nurse include that best
describes standard precautions? Select all that apply. - ANSWER >Wear gloves
when there is the potential for contact with a clientj's body fluid; >Wear gloves, a
face shield, and a gown when contact with body fluids is possible
The nurse preceptor is discussing Standard Precautions with a graduate nurse.
The preceptor should include which measures when discussing Standard
,Precautions? Select all that apply. - ANSWER >wear gloves when administering
intramuscular (IM) medication
>wash hands after removal of gloves
The physician orders contact precautions for a client with a draining wound.
Which action should the nurse take to initiate these precautions? - ANSWER
Place an isolation cart containing gloves and gowns outside the client's room.
A nurse is working at a local emergency department. A nearby building
explosion has occurred, and many of the victims involved are being brought to
the facility. Which client would the nurse expect to be triaged first? - ANSWER a
62-year-old with tachypnea
The nurse complies with a client's request to administer his medication at 9 p.m.
instead of 10 p.m. so he can go to sleep earlier. Which type of nursing
intervention is the nurse utilizing? - ANSWER independent
The charge nurse is making client care assignments. Which client is most
appropriate for a licensed practical nurse? - ANSWER A stable 6-month-old
infant with pneumonia
A clinical pathway is guiding care for a postpartum client who had an
uncomplicated vaginal delivery of an 8-lb, 2-oz (3,686-g) baby 24 hours ago. The
client has no episiotomy and is bottle-feeding her baby. Which outcome should
be achieved within the next 8 hours? - ANSWER Client will demonstrate ability to
bottle-feed the neonate.
A 33-year-old client who tested positive for the human immunodeficiency virus
(HIV) is admitted to the medical unit with pancreatitis. A nurse director from
another unit comes into the medical unit nurses' station and begins reading the
client's chart. The staff nurse questions the director, who says that the client is
her neighbor's son. What should the nurse do to protect the client's right to
privacy? - ANSWER Inform the nurse director that she's violating the client's
right to privacy and ask her to return the chart.
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver
oxygen to compromised tissues. Which condition would benefit from hyperbaric
oxygen therapy? - ANSWER compromised skin graft
After a physician explains the risks and benefits of a clinical trial to a client, the
client agrees to participate. Later that day, the client requests clarification of
the process involved in the clinical trial. As a member of the multidisciplinary
team, how should the nurse respond? - ANSWER Provide the information
requested
, A 75-year-old client who was admitted to the hospital with a stroke informs the
nurse that he doesn't want to be kept alive with machines. He wants to make
sure that everyone knows his wishes. Which action should the nurse take? -
ANSWER Make arrangements for the client to receive information about
advance directives
After undergoing a right lower lobectomy for treatment of lung cancer, a 75-
year-old client returns to his room with a chest tube in place. Several hours later
a nurse finds the client out of bed barely able to speak, with the chest tube
removed. Which action should the nurse take immediately? - ANSWER Cover the
insertion site with an occlusive dressing, call for assistance, and remain with the
client.
A client with end-stage pulmonary hypertension tells his physician that he
doesn't want any heroic measures should his heart stop and that he doesn't
want to be placed on a ventilator. The physician enters a do-not-resuscitate
order into the hospital's computer system. Which ethical principle is a nurse
upholding by supporting the client's decision? - ANSWER Autonomy
A nurse is working with the team to develop a neonate's plan of care. Which
action would be the highest priority in regulating the neonate's temperature? -
ANSWER Block sources of radiant, convective, conductive, and evaporative
losses.
The nurse, who is providing care for four clients, receives a report on the
clients. Which report is an outcome indicator? - ANSWER pain level 3/10 one
hour after administration of pain medication
Which finding is common when gathering data from a child with a total
anomalous pulmonary venous return defect? - ANSWER frequent respiratory
infections
A nurse is caring for a client who received pain medication before leaving the
post anesthesia care unit (PACU). Upon returning to the room, the client reports
pain and requests more pain medication. Which action is most appropriate for
the nurse to take? - ANSWER Obtain the client's vital signs.
The nurse suspects that a client is not swallowing the administered dose of an
anxiolytic medication and is concerned that the client may be disposing of it in
the trash. Which action should the nurse take first? - ANSWER Talk with the
client about the concerns.
A nurse is caring for a client who had abdominal surgery 3 days ago. The client
states, "I haven't moved my bowels, but I am passing gas." What nursing action
is appropriate for this client? - ANSWER Encourage the client to ambulate.
