PN Fundamentals 2017

PN Fundamentals 2017 A nurse is reinforcing teaching with a client who has a BMI of 27. Which of the following client statements indicates an understanding of the teaching? - ANSWER "I will increase my physical activity." Rationale: The client's BMI of 27 indicates that the client is within the overweight range of 25 to 29.9. Inactivity contributes to weight gain; therefore, increasing physical activity should promote a healthy weight, and reduce the client's risk for cardiovascular disease, diabetes, and hypertension. A nurse is preparing to administer an intermittent enteral feeding every 4 hr to a client who has an NG tube. Which of the following findings requires that the nurse withhold the feeding? - ANSWER Three episodes of diarrhea in the last 24 hr A licensed practical nurse (LPN) is planning care of a group of clients at the beginning of a shift. For which of the following clients should the nurse request a change in assignment? - ANSWER A client who requires evaluation of an established plan of care Rationale: Evaluating an established plan of care for a client requires advanced nursing knowledge and skill and is outside the scope of practice of an LPN. It is within the scope of practice of an LPN to assist in establishing the plan of care for a client. A nurse is reinforcing teaching with a group of adolescent clients about testicular self-examination. Which of the following instructions should the nurse include? - ANSWER Feel for lumps by rolling the testicles between the thumb and fingers. A home health nurse is reinforcing teaching about infection control with a client who has hepatitis A. The nurse should identify which of the following client statements indicates an understanding of the teaching? - ANSWER "I will wash my hands with soap and water for 15 seconds after having a bowel movement." A nurse is reviewing the laboratory data of a client who has AIDS. Which of the following laboratory findings indicates the need for a nutritional consultation? - ANSWER Hemoglobin 9.0 g/dL Rationale: This hemoglobin level is below the expected reference range of 12 to 18 g/dL, indicating anemia. A low hemoglobin level can indicate a deficiency of certain vitamins and minerals. A nurse is caring for a client who reports pruritus after taking a prescription medication. Which of the following is the priority action for the nurse to take? - ANSWER Monitor for manifestations of an allergic reaction. Rationale: The first action the nurse should take using the nursing process is to collect data from the client. The nurse should monitor the client for any manifestations that suggest anaphylaxis, such as airway constriction, throat swelling, shortness of breath, or severe wheezing. A nurse is providing postmortem care for a client. Which of the following actions should the nurse take first? - ANSWER Elevate the client's head A nurse is assisting with discharge planning for a client who has impaired mobility following a stroke and lives in an apartment with stairs. Which of the following members of the health care team should the nurse contact? - ANSWER Social Worker A nurse is assisting with the plan of care for a young adult client who is attending college and is living in a dormitory. The nurse should recommend a prescription for which of the following immunizations? - ANSWER Meningococcal conjugate immunization; Influenza immunization Rationale: Pneumococcal immunization is incorrect. This immunization is given to young adult clients who are immunocompromised and at risk for developing pneumonia. Respiratory syncytial virus immunization is incorrect. This immunization is only administered to infants who are premature and at risk.