NCLEX LPN Management of Care #4 questions completed 100%

NCLEX LPN Management of Care #4 questions completed 100%The nursing team consists of an RN, one LPN/LVN and two nursing assistants. The LPN/LVN should question which of the following client assignments? 1. The RN assigns the LPN/LVN to care for a client in Buck's traction. 2. The RN assigns the LPN/LVN to administer digoxin (Lanoxin) and furosemide (Lasix) via an NG tube. 3. The RN assigns the LPN/LVN to care for a client 48 hours after a hip replacement. 4. The RN assigns the LPN/LVN to care for a client 12 hours after a laminectomy with spinal fusion who is having difficulty voiding. Strategy: LPN/LVN cares for stable clients with expected outcomes. (1.) appropriate client for the LPN/LVN; stable client with expected outcome (2.) appropriate assignment for the LPN (3.) appropriate assignment for the LPN (4.) CORRECT— unstable patient, requires skills of RN On the day of discharge, a client newly diagnosed with diabetes says, "Tell me again, what should I do if I develop a fever?" Which of the following is the BEST response by the LPN/LVN? 1. "Increase your caloric intake and decrease your insulin dosage." 2. "Discontinue taking insulin until after your febrile state has passed." 3. "Continue to monitor blood sugar and take insulin as prescribed." 4. "See your physician to have your insulin dosage adjusted." Strategy: "BEST" indicates discrimination may be required to answer the question. (1.) need for insulin increases during illness; should test blood glucose every 3 to 4 hours; if usual meal plan can't be followed, substitute soft foods (2.) fever increases metabolic rate and release of glucose; need to continue taking insulin (3.) CORRECT — diabetic's need for insulin is increased with any concurrent illness, especially an infection; presence of a fever, inability to ingest food, and erratic blood glucose levels are all reasons for an immediate call to the physician (4.) contact physician if unable to control glucose level using guidelines provided An LPN/LVN cares for residents in an assisted living facility. The LPN/LVN discovers an unconscious client lying on the floor beside the bed with a small, open lesion on the right side of the head. After caring for the client, the LPN/LVN prepares to write an incident report. Which of the following entries is MOST appropriate for the incident report? 1. "The client apparently fell out of bed." 2. "Notified supervisor of the accidental head injury." 3. "Apparently struck right side of head during fall." 4. "Nonresponsive client found lying on floor beside bed." Strategy: "MOST appropriate" indicates that discrimination may be required to answer the question. (1) nurse did not make this observation; should only chart the facts (2) documenting notification of supervisor is appropriate for nurses' notes; no data to support conclusion of accidental head injury (3) no evidence that client fell nor that the head was struck in the process (4) CORRECT—incident should reflect exactly what the person completing the report saw, heard, touched, etc. 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? 1. Massage the lower limbs vigorously during the morning bath. 2. Assist the client with long, early morning walks. 3. Apply antipruritic lotion after completing the client's bath. 4. Measure vital signs q 4 hours. 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 (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? 1. Suggest the client remain in his home until his noise tolerance improves. 2. Contact the health care provider for a prescription for an antidepressant. 3. Instruct the client to wear headphones with music playing when he goes out. 4. Recommend that the client seek psychotherapy. 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 (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? 1. Orange juice. 2. Peanut butter. 3. Regular insulin. 4. NPH insulin. 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? 1. "A warm bath feels good." 2. "I am taking aspirin for the discomfort." 3. "I walked one mile on the treadmill today." 4. "I have increased my intake of fruits and fresh vegetables." 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. After receiving report, which of the following clients should the LPN/LVN see FIRST? 1. A client due to receive blood pressure medicine. 2. A client due to receive a metered dose inhaler (MDI). 3. A client whose family member is threatening to sue the institution if the LPN/LVN doesn't talk to them immediately. 4. A client who has been verbally abusive to staff and is becoming increasingly more agitated. Strategy: "FIRST" indicates priority. (1.) safety takes precedence over administration of routine; non-emergent medications (2.) safety takes precedence over administ