HESI PN FUNDAMENTALS EXAM PACK

HESI LPN FUNDAMENTALS EXAM PACK-MEREGED FROM 2019/2020/2021 ACTUAL EXAM-BEST FOR 2022 ACTUAL EXAM HESI LPN Fundamental 1) A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the LPN/LVN implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities. Correct Answer: A 2) When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the LPN implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse. Correct Answer: A 3) The LPN/LVN is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer. Correct Answer: B 4) A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. Correct Answer: D 5) While instructing a male client's wife in the performance of passive rangeof-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the LPN/LVN implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion. Correct Answer: A 6) What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. Correct Answer: B 7) The LPN observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure. Correct Answer: B 8) A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The LPN plans to administer the IVPB dose over 20 minutes. For how many ml/ hr should the infusion pump be set to deliver the secondary infusion? Correct Answer: 150 9) Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat. Correct Answer: D 10) The LPN is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase. Correct Answer: C 11) The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. Place the chair at a right angle to the bed on the client's left side before moving. B. Assist the client to a standing position, then place the right hand on the armrest. C. Have the client place the left foot next to the chair and pivot to the left before sitting. D. Move the chair parallel to the right side of the bed, and stand the client on the right foot. Correct Answer: D 12) An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the LPN/LVN provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level. Correct Answer: C 13) A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the LPN have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed. Correct Answer: B 14) The LPN/LVN observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin. Correct Answer: A 15) The LPN/LVN mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? A. 31 gtt/min. B. 62 gtt/min. C. 93 gtt/min. D. 124 gtt/min. Correct Answer: D 16) A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the LPN/LVN to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. Correct Answer: C 17) A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the LPN advise the client to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch and before dinner. D. With breakfast, with lunch, and with dinner. Correct Answer: B 18) A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the LPN/LVN set the client's intravenous infusion pump? A. 13 ml/hour. B. 63 ml/hour. C. 80 ml/hour. D. 125 ml/hour. Correct Answer: B 19) An obese male client discusses with the LPN/LVN his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation. Correct Answer: A 20) The LPN is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation. Correct Answer: B 21) The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the LPN/LVN plan to administer? A. ½ tablet. B. 1 tablet. C. 1½ tablets. D. 2 tablets. Correct Answer: C 22) The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the LPN/LVN administer? A. 1 ml. B. 1.5 ml. C. 1.75 ml. D. 2 ml. Correct Answer: B 23) Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units. Correct Answer: A 24) The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the LPN/LVN administer? A. 0.5 ml. B. 1 ml. C. 1.5 ml. D. 2 ml. Correct Answer: A 25) The LPN prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25 Correct Answer: C 26) Which action is most important for the LPN/LVN to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first. Correct Answer: C 27) A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding "stronger pain medications." What initial action is most important for the LPN/LVN to take? A. Ask about any past history of drug abuse or addiction. B. Measure the pulse volume and capillary refill distal to the infiltration. C. Compress the infiltrated tissue to measure the degree of edema. D. Evaluate the extent of ecchymosis over the forearm area. Correct Answer: B 28) An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine. Correct Answer: B 29) A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the LPN/LVN include in this client's teaching plan? A. In 8 weeks you will be able to bend at the waist to reach items on the floor. B. Place a pillow between your knees while lying in bed to prevent hip dislocation. C. It is safe to use a walker to get out of bed, but you need assistance when walking. D. Take pain medication 30 minutes after your physical therapy sessions. Correct Answer: B 30) A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the LPN/LVN implement first? A. Assist the ambulating client back to the bed. B. Encourage the client to ambulate to resolve pneumonia. C. Obtain a prescription for portable oxygen while ambulating. D. Move the oximetry probe from the finger to the earlobe. Correct Answer: A 31) A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the LPN/LVN take? A. Commend the client for selecting a high biologic value protein. B. Remind the client that protein in the diet should be avoided. C. Suggest that the client also select orange juice, to promote absorption. D. Encourage the client to attend classes on dietary management of CRF. Correct Answer: A 32) A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the LPN to include during the preoperative assessment? A. What is your daily calorie consumption? B. What vitamin and mineral supplements do you take? C. Do you feel that you are overweight? D. Will a clear liquid diet be okay after surgery? Correct Answer: B 33) During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the LPN/LVN implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water. Correct Answer: D 34) Which intervention is most important for the LPN/LVN to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention. Correct Answer: D 35) A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the LPN/LVN to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs q15 minutes for the first hour. D. Ensure the accuracy of the blood type match. Correct Answer: D 36) Which snack food is best for the LPN/LVN to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices. Correct Answer: A 37) The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the LPN that this client understands the dietary restrictions? A. Tossed salad, low-sodium dressing, bacon and tomato sandwich. B. New England clam chowder, no-salt crackers, fresh fruit salad. C. Skim milk, turkey salad, roll, and vanilla ice cream. D. Macaroni and cheese, diet Coke, a slice of cherry pie. Correct Answer: C 38) Which nutritional assessment data should the LPN/LVN collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference. Correct Answer: D 39) An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the LPN/LVN implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request. Correct Answer: D 40) After completing an assessment and determining that a client has a problem, which action should the LPN/LVN perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals. Correct Answer: A 41) An elderly client who requires frequent monitoring fell and fractured a hip. Which LPN/LVN is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred. Correct Answer: C 42) A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client A. asks relevant questions regarding the dressing change. B. states he will be able to complete the wound care regimen. C. demonstrates the wound care procedure correctly. D. has all the necessary supplies for wound care. Correct Answer: C 43) When evaluating a client's plan of care, the LPN determines that a desired outcome was not achieved. Which action will the LPN implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes. Correct Answer: B 44) The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The LPN/LVN plans to set the flow rate at how many gtt/min? A. 42 gtt/min. B. 83 gtt/min. C. 125 gtt/min. D. 250 gtt/min. Correct Answer: B 45) Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the LPN/LVN plan to administer? A. 0.5 tablet. B. 1 tablet. C. 1.5 tablets. D. 2 tablets. Correct Answer: B 46) Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A. Aspirating gastric contents to assure a pH value of 4 or less. B. Hearing air pass in the stomach after injecting air into the tubing. C. Examining a chest x-ray obtained after the tubing was inserted. D. Checking the remaining length of tubing to ensure that the correct length was inserted. Correct Answer: C 47) The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the LPN/LVN take? A. Infuse normal saline at a keep vein open rate. B. Discontinue the IV and flush the port with heparin. C. Infuse 10 percent dextrose and water at 54 ml/hr. D. Obtain a stat blood glucose level and notify the healthcare provider. Correct Answer: C 48) When assisting an 82-year-old client to ambulate, it is important for the LPN/LVN to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet. Correct Answer: B 49) In developing a plan of care for a client with dementia, the LPN/LVN should remember that confusion in the elderly A. is to be expected, and progresses with age. B. often follows relocation to new surroundings. C. is a result of irreversible brain pathology. D. can be prevented with adequate sleep. Correct Answer: B 50) An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The LPN knows that the best position for this client during administration of the feedings is A. prone. B. Fowler's. C. Sims'. D. supine. Correct Answer: B 51) The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the LPN take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering. Correct Answer: B 52) When conducting an admission assessment, the LPN should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices. Correct Answer: C 53) A young mother of three children complains of increased anxiety during her annual physical exam. What information should the LPN/LVN obtain first? A. Sexual activity patterns. B. Nutritional history. C. Leisure activities. D. Financial stressors. Correct Answer: B 54) Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure. Correct Answer: B 55) At the time of the first dressing change, the client refuses to look at her mastectomy incision. The LPN tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A. It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel. B. Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery. C. It is OK if you don't want to talk about your surgery. I will be available when you are ready. D. I will ask a woman who has had a mastectomy to come by and share her experiences with you. Correct Answer: C Fundamental PN Hesi V2 1) During the initial physical assessment of a newly admitted client with a pressure ulcer, a LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? A The nurse also should have instituted a plan to increase activity. B The nurse provided supportive nursing care for the well-being of the client. C Debridement of the pressure ulcer should have been done before the dressing was applied. D Treatment should not have been instituted until the health care provider's prescriptions were received. Correct Answer: B 2) A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the LPN/LVN needs to take? A Ask the client if he is okay. B Call security from the room. C Find out if there is anyone else in the room. D Ask security to make sure the room is safe Correct Answer: D 3) To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the LPN should change the administration set every: A 4 to 8 hours B 12 to 24 hours C 24 to 48 hours D 72 to 96 hours Correct Answer: D 4) A LPN/LVN is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. A Ask the client what is the client's acceptable level of pain. B Eliminate all activities that precipitate the pain. C Administer the pain medications regularly around the clock. D Use a different pain scale each time to promote patient education. E Assess the client's pain every 15 minutes Correct Answer: A, C 5) The LPN/LVN is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. A Allergy to the medication B Itching in the ear canal C Drainage from the ear canal D Tympanic membrane rupture E Partial hearing loss in the affected ear Correct Answer:A,C,D 6) What clinical indicators should the LPN/LVN expect a client with hyperkalemia to exhibit? Select all that apply. A Tetany B Seizures C Diarrhea D Weakness E Dysrhythmias Correct Answer:C,D,E 7) A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the LPN give the client about this medication? A Prolonged use can cause dark concentrated urine. B The medication is best absorbed when taken on an empty stomach. C Take the medication with aluminum hydroxide to minimize GI upset. D Drinking alcohol daily can cause drug-induced hepatitis Correct Answer:D 8) To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the LPN/LVN expect the dietary plan to include? A Low in fat B High in iron C High in fluids D Low in residue Correct Answer:C 9) A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the LPN/LVN best handle this situation? A Tell the neighboring client to stop singing. B Close the doors to both clients' rooms at night. C Give the complaining client the prescribed as needed sedative. D Move the neighboring client to a room at the end of the hall Correct Answer:D 10) The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The LPN should monitor for what complication associated with this type of surgery? A Occipital headache B Periorbital crepitus C Expectoration of blood D Changes in vocalization Correct Answer:C 11) A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the LPN/LVN question? A Oral psyllium (Metamucil) B Oral potassium supplement C Parenteral half normal saline D Parenteral albumin (Albuminar) Correct Answer:D 12) A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the LPN/LVN monitor this client? A Curling ulcer B Renal shutdown C Metabolic acidosis D Hemolysis of red blood cells Correct Answer:C 13) A LPN is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. A Clean the eyelid and eyelashes. B Place the dropper against the eyelid. C Apply clean gloves before beginning of procedure. D Instill the solution directly onto cornea. E Press on the nasolacrimal duct after instilling the solution. Correct Answer:A,C,E 14) The LPN/LVN recognizes that which are important components of a neurovascular assessment? Select all that apply. A Orientation B Capillary refill C Pupillary response D Respiratory rate E Pulse and skin temperature F Movement and sensation Correct Answer: B,E,F 15) A client reaches the point of acceptance during the stages of dying. What response should the LPN/LVN expect the client to exhibit? A Apathy B Euphoria C Detachment D Emotionalism Correct Answer: C 16) A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the LPN/LVN primarily use nonverbal interventions? A Anger B Denial C Bargaining D Acceptance Correct Answer: D 17) When a client files a lawsuit against a LPN for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: A Evidence B Tort discovery C Proximate cause D Common cause Correct Answer:C 18) Following a surgery on the neck, the client asks the LPN why the head of the bed is up so high. The LPN should tell the client that the high-Fowler position is preferred for what reason? A To avoid strain on the incision B To promote drainage of the wound C To provide stimulation for the client D To reduce edema at the operative site Correct Answer: D 19) The LPN is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? A Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. B Develop a chart for the client, listing the times the medication should be taken. C Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. D Instruct the client and client's children to put medications in a weekly pill organizer Correct Answer: C 20) The LPN/LVN expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. A Dyspnea B Flushed face C Precordial pain D Increased pulse rate E Increased blood pressure Correct Answer: B,D 21) The LPN/LVN should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: A Force urine to back up into the kidneys. B Suppress production of urine. C Cause the device to pull away from the skin. D Tear the ileal conduit Correct Answer: C 22) A LPN is reviewing studies to answer a clinical question as part of an evidence-based practice project. The study design determines the level of evidence. Place each methodology in order from the most reliable to the least reliable. A Meta-analysis B Randomized controlled trial C Expert opinion based on scientific principles D Cohort study E Controlled trial without randomization Correct Answer: A 23) Client expresses concern about being exposed to radiation therapy because it can cause cancer. What should the LPN emphasize when informing the client about exposure to radiation? A The dosage is kept at a minimum. B Only a small part of the body is irradiated. C The client's physical condition is not a risk factor. D Nutritional environment of the affected cells is a risk factor. Correct Answer: B 24) The triage LPN in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? A Multipara in active labor B Middle-aged woman with substernal chest pain C Older adult male with a partially amputated finger D Adolescent boy with an oxygen saturation of 91% Correct Answer: C 25) Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? A Encouraging daily physical exercise B Performing yearly physical examinations C Providing hypertension screening programs D Teaching a person with diabetes how to prevent complications Correct Answer: A 26) A LPN/LVN who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response by the LPN/LVN? A "We have no record of that client on our unit. Thank you for calling." B "The new privacy laws prevent me from providing any client information over the phone." C "The client has requested that no information be given out. You'll need to call the client directly." D "It is against the hospital's policy to provide you with any information regarding any of our clients." Correct Answer: A 27) When being interviewed for a position as a registered professional LPN, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? A Negligence B Malpractice C Breach of duty D False imprisonment Correct Answer: D 28) The LPN/LVN plans care for a client with a somatoform disorder based on the understanding that the disorder is: A A physiological response to stress B A conscious defense against anxiety C An intentional attempt to gain attention D An unconscious means of reducing stress Correct Answer: D 29) A LPN is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? A Droplet precautions B Reverse isolation C Surgical asepsis D Medical asepsis Correct Answer: C 30) Alternative therapy measures have become increasingly accepted within the past decade, especially in the relief of pain. Which methods qualify as alternative therapies for pain? Select all that apply. A Prayer B Hypnosis C Medication D Aromatherapy E Guided imagery Correct Answer:A,B,D,E 31) A LPN is teaching an adolescent about type 1 diabetes and selfcare. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. A "What is diabetes?" B "What will my friends think?" C "How do I give myself an injection?" D "Can you tell me how the glucose monitor works?" E"How do I get the insulin from the vial into the syringe? Correct Answer:A,D 32) Place each step of the nursing process in the order that it should be used. Correct A Obtain client's nursing history. Correct B State client's nursing needs. Correct C Identify goals for care. Correct D Develop a plan of care. Correct E Implement nursing interventions. Correct Answer:A,B,C,D,E 33) In what position should the LPN/LVN place a client recovering from general anesthesia? A Supine B Side-lying C High Fowler E Trendelenburg Correct Answer: B 34) Which age-related change should the LPN/LVN consider when formulating a plan of care for an older adult? Select all that apply. A Difficulty in swallowing B Increased sensitivity to heat C Increased sensitivity to glare D Diminished sensation of pain E Heightened response to stimuli Correct Answer: C,D 35) The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the LPN/LVN take? A Institute the prescribed blood transfusion because the client's survival depends on volume replacement. B Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. C Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. D Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought Correct Answer: D 36) Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her health care provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? A Give the infant to the client and instruct her regarding the infant's care. B Explain to the client that she can leave, but her infant must remain in the hospital. C Emphasize to the client that the infant is a minor and legally must remain until prescriptions are received. D Tell the client that hospital policy prevents the staff from releasing the infant until ready for discharge Correct Answer:A 37) A client reports fatigue and dyspnea and appears pale. The LPN/ LVN questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? A Famotidine (Pepcid) B Methyldopa (Aldomet) C Ferrous sulfate (Feosol) D Levothyroxine (Synthroid) Correct Answer:B 38) The LPN/LVN assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: A faint, barely detectable. B slightly weak, palpable. C normal. D bounding. Correct Answer:C 39) A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the LPN puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? A Limits had to be set to control the child's crying. B The child had a right to remain in the room with the other children. C The child had to be removed because the other children needed to be considered. D Segregation of the child for more than half an hour was too long a period of time Correct Answer: B 40) An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the LPN must consider? Select all that apply. A Assessment of skin turgor B Documentation of vital signs C Assessment of intake and output D Administration of antiemetic drugs E Replacement of fluid and electrolytes Correct Answer:A,D,E 41) What should the LPN/LVN consider when obtaining an informed consent from a 17-year-old adolescent? A If the client is allowed to give consent B The client cannot make informed decisions about health care. C If the client is permitted to give voluntary consent when parents are not available D The client probably will be unable to choose between alternatives when asked to consent Correct Answer: A 42) Which nursing activities are examples of primary prevention? Select all that apply. A Preventing disabilities B Correcting dietary deficiencies C Establishing goals for rehabilitation D Assisting with immunization program E Stopping smoking Correct Answer: D,E 43) An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply. A Difficulty in swallowing B Diminished sensation of pain C Heightened response to stimuli D Impaired hearing of high-frequency sounds E Increased ability to tolerate environmental heat Correct Answer: B,D 44) A nurse receives a subpoena in a court case involving a child. The nurse is preparing to appear in court. In addition to the state Nurse Practice Act and the American Nursing Association (ANA) Code for Nurses, what else should the nurse review? A Nursing's Social Policy Statement B State law regarding protection of minors C ANA Standards of Clinical Nursing Practice D References regarding a child's right to consent Correct Answer: C 45) A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the LPN monitor the client? Select all that apply. A Tremors B Lethargy C Palpitations D Visual disturbances E Decreased pulse rate Correct Answer: A,C 46) A client asks about the purpose of a pulse oximeter. The LPN/LVN explains that it is used to measure the: A Respiratory rate. B Amount of oxygen in the blood. C Percentage of hemoglobin-carrying oxygen. D Amount of carbon dioxide in the blood Correct Answer: C 47) A client comes to the clinic complaining of a productive cough with copious yellow sputum, fever, and chills for the past two days. The first thing the LPN/LVN should do when caring for this client is to: A Encourage fluids. B Administer oxygen. C Take the temperature. D Collect a sputum specimen Correct Answer: E 48) A LPN/LVN is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include: A A loss of skin elasticity and a decrease in libido B Impaired fat digestion and increased salivary secretions C Increased blood pressure and decreased hormone production D An increase in body warmth and some swallowing difficulties Correct Answer: E 49) A client has been diagnosed as brain dead. The LPN/LVN understands that this means that the client has: A No spontaneous reflexes B Shallow and slow breathing C No cortical functioning with some reflex breathing D Deep tendon reflexes only and no independent breathing Correct Answer: D 50) A LPN/LVN cares for a client that has been bitten by a large dog. A bite by a large dog can cause which type of trauma? A Abrasion B Fracture C Crush injury D Incisional laceration Correct Answer: C 51) A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the LPN consider about how gamma globulin provides passive immunity? A It increases production of short-lived antibodies. B It accelerates antigen-antibody union at the hepatic sites. C The lymphatic system is stimulated to produce antibodies. D The antigen is neutralized by the antibodies that it supplies Correct Answer: D 52) A LPN is caring for a client with an impaired immune system. Which blood protein associated with the immune system is important for the nurse to consider? A Albumin B Globulin C Thrombin D Hemoglobin Correct Answer: B 53) A LPN discusses the philosophy of Alcoholics Anonymous (AA) with the client who has a history of alcoholism. What need must selfhelp groups such as AA meet to be successful? A Trust B Growth C Belonging D Independence Correct Answer: C 54) What type of interview is most appropriate when a LPN/LVN admits a client to a clinic? A Directive B Exploratory C Problem solving D Information giving Correct Answer: A 55) A client reaches the point of acceptance during the stages of dying. What response should the LPN/LVN expect the client to exhibit? A Apathy B Euphoria C Detachment D Emotionalism Correct Answer: C HESI PNFundamentals Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibitformation of aqueous humor for a client with glaucoma? Chlorothiazide (Diuril) Acetazolamide (Diamox) Bendroflumethiazide (Naturetin) Demecarium bromide (Humorsol) A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me, and I don't know why this is happening." What is the nurse's best response? Tell the client it is nothing to worry about. Talk with the client further to identify the specific cause of the problem.Instruct the client to attempt to avoid situations that cause irritation. Interview the client to determine whether other mood swings are being experienced. A client receiving steroid therapy states, "I have difficulty controlling my temper which is sounlike me, and I don't know why this is happening." What is the nurse's best response? Tell the client it is nothing to worry about. Talk with the client further to identify the specific cause of the problem.Instruct the client to attempt to avoid situations that cause irritation. Interview the client to determine whether other mood swings are being experienced. The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains thatthe rationale for these interventions is to: Promote equalization of osmotic pressures. Prevent hypoxia associated with diaphoresis. Promote integrity of intracerebral neurons. Reduce brain metabolism and limit hypoxia. A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. mL 1.5 The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? Risk for pressure ulcer Risk for impaired skin integrity Impaired skin integrity, related to infrequent turning and repositioning Impaired skin integrity, related to the effects of pressure and shearing force 1 A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissuedown to the underlying fascia. The nurse should document the assessment finding as whichstage of pressure ulcer? Stage I Stage II Stage III Unstageable A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before thewound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneousfat. Bone, tendon, and muscle are not exposed. A client is being admitted for a total hip replacement. When is it necessary for the nurse toensure that a medication reconciliation is completed? Select all that apply. After reporting severe pain On admission to the hospital Upon entering the operating room Before transfer to a rehabilitation facility At time of scheduling for the surgical procedure Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to adifferent setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted. A client is taking lithium sodium (Lithium). The nurse should notify the health care provider forwhich of the following laboratory values? White blood cell (WBC) count of 15,000 mm3 Negative protein in the urine Blood urea nitrogen (BUN) of 20 mg/dL Prothrombin of 12.0 seconds White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these arenormal values. Often when a family member is dying, the client and the family are at different stages ofgrieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? Anger Denial 2 Depression Acceptance In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at thesame time. During depression, the family often is able to offer emotional support, which meets theirneeds. The client asks the nurse to recommend foods that might be included in a diet for diverticulardisease. Which foods would be appropriate to include in the teaching plan? Select all that apply. Whole grains Cooked fruit and vegetables Nuts and seeds Lean red meats Milk and eggs With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggshave no fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats. A nurse is obtaining a health history from the newly admitted client who has chronic pain inthe knee. What should the nurse include in the pain assessment? Select all that apply. Pain history, including location, intensity, and quality of pain Client's purposeful body movement in arranging the papers on the bedside tablePain pattern, including precipitating and alleviating factors Vital signs such as increased blood pressure and heart rate The client's family statement about increases in pain with ambulation Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of painincludes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipateand meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members. While undergoing a soapsuds enema, the client reports abdominal cramping. What actionshould the nurse take? 3 Immediately stop the infusion. Lower the height of the enema bag. Advance the enema tubing 2 to 3 inches. Clamp the tube for 2 minutes, then restart the infusion. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps. During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? The nurse also should have instituted a plan to increase activity. The nurse provided supportive nursing care for the well-being of the client. Debridement of the pressure ulcer should have been done before the dressing was applied Treatment should not have been instituted until the health care provider's prescriptions were received. According to the Nurse Practice Act, a nurse may independently treat human responses to actual or potential health problems. An activity level is prescribed by a health care provider; this is a dependentfunction of the nurse. There is not enough information to come to the conclusion that debridement should have been done before the dressing was applied. Application of an emollient and reinforcing adressing are independent nursing functions. A visitor comes to the nursing station and tells the nurse that a client and his relative had afight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? Ask the client if he is okay. Call security from the room. Find out if there is anyone else in the room.Ask security to make sure the room is safe Safety is the first priority when responding to a presumably violent situation. The nurse needs to havesecurity enter the room to ensure it is safe. Then it can be determined if the client is okay and make sure that any other people in the room are safe To ensure the safety of a client who is receiving a continuous intravenous normal salineinfusion, the nurse should change the administration set every: 4 to 8 hours 12 to 24 hours 24 to 48 hours 72 to 96 hours Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 4 hours after initiation of use in patients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48hours is not a cost-effective practice A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select allthat apply. Ask the client what is the client's acceptable level of pain. Eliminate all activities that precipitate the pain. Administer the pain medications regularly around the clock. Use a different pain scale each time to promote patient education. Assess the client's pain every 15 minutes The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute pain, the goal of the pain management is to decrease pain to thetolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide the stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level helps to ensureconsistency and accuracy in the pain assessment. Only management of acute pain such as postoperative pain requires the pain assessment at frequent intervals. The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. Allergy to the medication Itching in the ear canal Drainage from the ear canal Tympanic membrane rupture Partial hearing loss in the affected ear Contraindications to eardrops include allergy to the medication, drainage from the ear canal, andtympanic membrane rupture. Partial hearing loss may occur with impacted cerumen and is not acontraindication to the use of eardrops. Itching may occur with some ear conditions and is not a contraindication to the use of eardrops. What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Selectall that apply. Tetany Seizures Diarrhea Weakness Dysrhythmias Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are associated with 5 low calcium or sodium levels. Because of potassium's role in the sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac dysrhythmias. A health care provider has prescribed isoniazid (Laniazid) for a client. Which instructionshould the nurse give the client about this medication? Prolonged use can cause dark concentrated urine. The medication is best absorbed when taken on an empty stomach. Take the medication with aluminum hydroxide to minimize GI upset. Drinking alcohol daily can cause drug-induced hepatitis Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause dark concentrated urine. The client should take isoniazid with meals to decrease GI upset. Clients shouldavoid taking aluminum antacids at the same time as this medication because it impairs absorption. To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what doesthe nurse expect the dietary plan to include? Low in fat High in iron High in fluids Low in residue A common side effect of vincristine is a paralytic ileus that results in constipation. Preventative measures include high-fiber foods and fluids that exceed minimum requirements. These will keep thestool bulky and soft, thereby promoting evacuation. Low in fat, high in iron, and low in residue dietaryplans will not provide the roughage and fluids needed to minimize the constipation associated with vincristine. A postoperative client says to the nurse, "My neighbor, I mean the person in the next room,sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? Tell the neighboring client to stop singing. Close the doors to both clients' rooms at night. Give the complaining client the prescribed as needed sedative.Move the neighboring client to a room at the end of the hall Moving the client who is singing away from the other clients diminishes the disturbance. A client with dementia will not remember instructions. It is unsafe to close the doors of clients' rooms because theyneed to be monitored. The use of a sedative should not be the initial intervention The nurse is providing postoperative care to a client who had a submucosal resection (SMR)for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? Occipital headache Periorbital crepitus Expectoration of blood Changes in vocalization 6 After an SMR, hemorrhage from the area should be suspected if the client is swallowing frequently orexpelling blood with saliva. A headache in the back of the head is not a complication of a submucosalresection. Crepitus is caused by leakage of air into tissue spaces; it is not an expected complication of SMR. The nerves and structures involved with speech are not within the operative area. However,the sound of the voice is altered temporarily by the presence of nasal packing and edema. A nurse is reviewing a plan of care for a client who was admitted with dehydration as a resultof prolonged watery diarrhea. Which prescription should the nurse question? Oral psyllium (Metamucil) Oral potassium supplement Parenteral half normal saline Parenteral albumin (Albuminar) Albumin is hypertonic and will draw additional fluid from the tissues into the intravascular space. Oralpsyllium will absorb the watery diarrhea, giving more bulk to the stool. An oral potassium supplementis appropriate because diarrhea causes potassium loss. Parenteral half normal saline is a hypotonic solution, which can correct dehydration. A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which seriousside effect of mafenide therapy should the nurse monitor this client? Curling ulcer Renal shutdown Metabolic acidosis Hemolysis of red blood cells Mafenide interferes with the kidneys' role in hydrogen ion excretion, resulting in metabolic acidosis.Curling ulcer, renal shutdown, and hemolysis of red blood cells are not adverse effects of the drugs. A nurse is preparing to administer an ophthalmic medication to a client. What techniquesshould the nurse use for this procedure? Select all that apply. Clean the eyelid and eyelashes. Place the dropper against the eyelid. Apply clean gloves before beginning of procedure. Instill the solution directly onto cornea. Press on the nasolacrimal duct after instilling the solution. Cleaning of the eyelids and eyelashes helps to prevent contamination of the other eye and lacrimal duct. Application of gloves helps to prevent direct contact of the nurse with the client's body fluids. Applying pressure to the nasolacrimal duct prevents the medication from running out of the eye. The dropper should not touch the eyelids or eyelashes in order to prevent contamination of the medicationin the dropper. The medication should not be instilled directly onto the cornea because cornea has many pain fibers and is therefore very sensitive. The medication is to be instilled into the lower conjunctival sac. The nurse recognizes that which are important components of a neurovascular assessment?Select all that apply. 7 Orientation Capillary refill Pupillary response Respiratory rate Pulse and skin temperature Movement and sensation A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic and/or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate arecomponents of a neurological assessment. A client reaches the point of acceptance during the stages of dying. What response should thenurse expect the client to exhibit? Apathy Euphoria Detachment Emotionalism When an individual reaches the point of being intellectually and psychologically able to accept death, anxiety is reduced and the individual becomes detached from the environment. Although detached, the client is not apathetic but still may be concerned and use time constructively. Although resigned todeath, the individual is not euphoric. In the stage of acceptance, the client is no longer angry or depressed. A dying client is coping with feelings regarding impending death. The nurse bases care on thetheory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? Anger Denial Bargaining Acceptance Communication and interventions during the acceptance stage are mainly nonverbal (e.g., holding theclient's hand). The nurse should be quiet but available. During the anger stage the nurse should accept that the client is angry. The anger stage requires verbal communication. During the denial stage the nurse should accept the client's behavior but not reinforce the denial. The denial stage requires verbal communication. During the bargaining stage the nurse should listen intently but not provide false reassurance. The bargaining stage requires verbal communication. When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. Thisis known as: Evidence Tort discovery 8 Proximate cause Common cause Proximate cause is the legal concept meaning that the client must prove that the nurse's actions contributed to or caused the client's injury. Evidence is data presented in proof of the facts, which mayinclude witness testimony, records, documents, or objects. A tort is a wrongful act, not including a breach of contract of trust that results in injury to another person. Common cause means to unite one's interest with another's. Following a surgery on the neck, the client asks the nurse why the head of the bed is up sohigh. The nurse should tell the client that the high-Fowler position is preferred for what reason? To avoid strain on the incision To promote drainage of the woundTo provide stimulation for the client To reduce edema at the operative site This position prevents fluid accumulation in the tissue, thereby minimizing edema. This position will neither increase nor decrease strain on the suture line. Drainage from the wound will not be affectedby this position. This position will not affect the degree of stimulation. The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication r