(Solutions) LVN NCLEX REVIEW TEST BANK 2022 with rationale.
LVN NCLEX REVIEW TEST BANK. The nurse is assessing the psychosocial status of a postpartum client. Which statement indicates that the mother is likely to have a successful parent-neonate attachment? a) "My previous experience was so awesome!" b) "I want to lie skin to skin with my baby for as long as possible after delivery." c) "Bonding is important to my baby's development." d) "I want to bond with my baby right away." (answer)- b) "I want to lie skin to skin with my baby for as long as possible after delivery." Reason: Sustained parent-neonate contact immediately after delivery is most likely to promote parent-neonate attachment. The first period of neonatal reactivity, which occurs during the first hour after delivery, is the ideal time for behavior that promotes attachment, such as touching, holding, talking, examining, and breast-feeding. Although parental desire to bond and understanding of the importance of bonding can contribute to parent-neonate attachment, early contact is a prerequisite. A previous positive childbirth experience may enhance parent-neonate attachment but is less crucial than sustained contact immediately after delivery A client had a laxative prescribed that acts by causing stool to absorb water and swell. Which term describes this type of laxative? a) Emollient b) Bulk-forming c) Stimulant d) Lubricant (answer) - b) Bulk-forming Reason: Bulk-forming laxatives cause stool to absorb water and swell. Emollients lubricate stool; lubricants soften stool, making it easier to pass. Stimulants promote peristalsis by irritating the intestinal mucosa or stimulating nerve endings in the intestinal wall The nurse is caring for a client with celiac disease. How should the nurse evaluate the effectiveness of nutritional therapy? a) Measure blood urea nitrogen and serum creatinine levels. b) Measure intake and output. c) Monitor vital signs every 4 hours. d) Monitor the appearance, size, and number of stools. (answer) - d) Monitor the appearance, size, and number of stools. Reason: When a client with celiac disease is placed on a gluten-free diet, fat, bulky, foulsmelling stools should be eliminated. This indicates that the disease is controlled and the client is using nutrients effectively. Taking vital signs, measuring blood urea nitrogen and serum creatinine levels, and measuring intake and output don't provide an indication of the effectiveness of diet therapy What elements must be proven by a client's attorney in the case of a professional negligence action? a) Duty, breach of duty, and damages b) Duty, damages, and causation c) Breach of duty, damages, and causation d) Duty, breach of duty, damages, and causation (answer) - d) Duty, breach of duty, damages, and causation Reason: Any professional negligence action must meet certain demands in order to be considered negligence and result in legal action. They're commonly known as the four D's: duty of the health care professional to provide care to the person making the claim, a dereliction (breach) of that duty, damages resulting from that breach of duty, and evidence that damages were directly due to negligence (causation) The infection control nurse is making rounds to ensure that airborne precautions are being observed while caring for clients with tuberculosis. Which action by the staff nurse requires further education? a) The nurse double-bags respiratory secretions. b) The nurse dons a surgical isolation mask when entering the client's room. c) The client's meals are served on disposable trays. d) The nurse gathers disposable client care items. (answer)- b) The nurse dons a surgical isolation mask when entering the client's room. Reason: When entering the room of a client with tuberculosis, the nurse should wear an N95 particulate respirator mask because surgical isolation masks allow turbide bacilli to pass through. All trash and waste should be disposed of as infectious waste. All client care items and meal trays should be disposable The nurse is caring for a client who underwent internal fixation of the right hip. Before administering the client's warfarin, the nurse checks the laboratory report for the client's International Normalized Ratio (INR) results. Which of the following indicates the therapeutic range for this client? a) 1.0 to 2.0 b) 2.0 to 3.0 c) 1.5 to 2.0 d) 3.0 to 4.0 (answer) - b) 2.0 to 3.0 Reason: Recent guidelines recommend an INR of 2.0 to 3.0 for clients without mechanical prosthetic heart valves who are receiving warfarin therapy. For clients with mechanical prosthetic heart valves, an INR of 2.5 to 3.5 is suggested. An INR below 2.0 is subtherapeutic with warfarin therapy. An INR above 3.0 in a client without a prosthetic valve indicates the need to reduce the warfarin dose. A nurse is caring for a client with multiple myeloma. What is a sign that a client with multiple myeloma isn't coping well with his prognosis? a) He shows concern about his family during his treatment. b) He avoids any conversation concerning his health. c) He becomes tearful when discussing his condition. d) He asks questions about his prognosis. (answer) - b) He avoids any conversation concerning his health. Reason: A client with multiple myeloma who avoids conversation may be denying his condition, which can interfere with treatment. Crying is a normal response to his disease. Asking questions about his prognosis is a normal coping response, as is showing concern for his family. The nurse educator is presenting an in-service on pediatric assessments. Why should the educator instruct nursing staff to inspect first and then auscultate when collecting data on a pediatric clients? a) Because the nurse's touch may frighten the child b) Because the nurse's hand or stethoscope may feel cold, making the child recoil c) Because the child may cry as data collection proceeds, making auscultation difficult d) Because the nurse's touch may calm the child (answer) - c) Because the child may cry as data collection proceeds, making auscultation difficult Reason: Because other data collection procedures may make the child cry, the nurse should auscultate the child's lungs immediately after inspection. Crying increases the respiratory rate and creates noise that interferes with clear auscultation The nurse is trying to establish rapport with a newly admitted client. Which statements will facilitate effective communication? Select all that apply. a) "Why are you crying?" b) "Tell me about your treatment so far." c) "What did your physician tell you about your need for hospitalization?" d) "Everything will be all right." e) "Did you take your medicine yesterday?" (answer)- c) "What did your physician tell you about your need for hospitalization?" b) "Tell me about your treatment so far Reason: Giving advice, providing false reassurance, and asking the client why he or she is crying is judgmental, all of which block rather than promote effective communication with a client. Asking open-ended questions and using leading questions promote effective communication A first-term nursing student is preparing to use a stethoscope to auscultate a client's chest. The nursing instructor asks the student to explain the working of the stethoscope. Which statement, provided by the student, about a stethoscope with a bell and diaphragm is true? a) "The diaphragm detects low-pitched sounds best." b) "The bell detects high-pitched sounds best." c) "The bell detects thrills best." d) "The diaphragm detects high-pitched sounds best." (answer)- d) "The diaphragm detects high-pitched sounds best." Reason: The diaphragm of a stethoscope detects high-pitched sounds best; the bell detects lowpitched sounds best. Palpation detects thrills best. A nurse is caring for a client who was admitted to the emergency department after a motor vehicle collision. Under the law, informed consent before treatment must be obtained unless which circumstance exists? a) The client asks the nurse to give substituted consent. b) The client refuses to give informed consent. c) The client is in an emergency situation. d) The client is mentally ill. (answer)- c) The client is in an emergency situation. Reason: The law doesn't require informed consent in an emergency situation when the client is unable to give consent and no next of kin is present. A mentally competent client may refuse or revoke consent at any time. The client may also refuse treatment. Even though a client who has been declared mentally incompetent can't give informed consent, mental illness doesn't by itself indicate that the client is incompetent to give informed consent. Although the nurse may act as a client advocate, the nurse can never give substituted consent. The nurse prepares to measure a client's blood pressure. What correct procedure for measuring blood pressure would the nurse utilize? a) Wrapping the cuff around the limb, with the uninflated bladder covering about one-fourth of the limb circumference b) Using a bladder that is 6" (15 cm) long c) Wrapping the cuff around the limb, with the uninflated bladder covering about three-fourths of the limb circumference d) Measuring the arm about 2" (5 cm) above the antecubital space (answer)- c) Wrapping the cuff around the limb, with the uninflated bladder covering about three-fourths of the limb circumference Reason: When measuring blood pressure, the nurse should place the cuff 1" (2.5 cm) above the brachial pulse and then wrap the cuff around the client's arm or leg with the bladder uninflated; the bladder should cover approximately three-fourths (not one-fourth) of the limb circumference. Bladder size is chosen according to the size of the extremity. A client who has recently had surgery for prostate cancer expresses to the nurse feelings of anger toward God, his church, and the clergy. Which nursing intervention is appropriate for this client? a) Invite the client's clergyman to visit. b) Avoid discussions about religious beliefs and practices. c) Ignore the client's spiritual distress. d) Encourage the client to discuss concerns with a clergy member. (answer)- d) Encourage the client to discuss concerns with a clergy member. Reason: Encouraging the client who is spiritually distressed following cancer surgery to discuss his concerns with a clergy member is an appropriate intervention. The nurse should also encourage the client to discuss his religious beliefs and practices. Ignoring the client's spiritual distress doesn't build a therapeutic relationship with the client. The nurse shouldn't invite a clergyman to visit the client, unless the client specifically asks to see that member of the clergy A client with a history of heart disease is given a prescription for 4 grains of aspirin which comes in 81 mg per tablet. The client asks the nurse, "how many tablets should I take?" What is the nurse's best response? Round to the nearest whole number. (answer)- 3 tablets 4 grains x 60 mg = 240 mg/81 mg = 2.96=3 tabs A client begins taking haloperidol. After a few days, he experiences severe tonic contractures of muscles in the neck, mouth, and tongue. The nurse should recognize this as: a) akathisia. b) psychotic symptoms. c) dystonia. d) parkinsonism. (answer)- c) dystonia ******************************CONTINUED************************
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lvn nclex review questions and answers
