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The LPN/LVN is preparing to ambulate a postoperative client after cardiac
surgery. The nurse plans to do which to enable the client to besttolerate the
ambulation?
Provide the client with a walker.
Remove the telemetry equipment.
Encourage the client to cough and deep breathe.
Premedicate the client with an analgesic before ambulating.
Correct Answer: 4. Premedicate the client with an analgesic beforeambulating.
A client is wearing a continuous cardiac monitor, which begins toalarm at the
nurse's station. The nurse sees no electrocardiographic complexes on the screen.
The nurse should do which first?
Call a code blue.
Call the health care provider.
Check the client status and lead placement.
Press the recorder button on the ECG console.
Correct Answer: 3. Check the client status and lead placement.
The LPN/LVN in a medical unit is caring for a client with heart failure. The client
suddenly develops extreme dyspnea, tachycardia, andlung crackles, and the nurse
suspects pulmonary edema. The nurse immediately notifies the registered nurse
and expects which interventions to be prescribed? Select all that apply.
Administering oxygen
Inserting a Foley catheter
Administering furosemide (Lasix)
Administering morphine sulfate intravenously
Transporting the client to the coronary care unit
1
,Placing the client in a low-Fowler's side-lying position
Correct Answer:
Administering oxygen
Inserting a Foley catheter
Administering furosemide (Lasix)
The nurse is monitoring a client following cardioversion. Whichobservations
should be of highest priority to the nurse?
Blood pressure
Status of airway
Oxygen flow rate
Level of consciousness
Correct Answer: 2. Status of airway
The nurse is assisting in caring for the client immediately after insertion of a
permanent demand pacemaker via the right subclavianvein. The nurse prevents
dislodgement of the pacing catheter by implementing which intervention?
Limiting movement and abduction of the left arm
Limiting movement and abduction of the right arm
Assisting the client to get out of bed and ambulate with a walker
Having the physical therapist do active range of motion to the rightarm
Correct Answer: 2. Limiting movement and abduction of the right arm
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest
pain and shortness of breath, and the client is visibly anxious. The LPN/LVN
understands that a life-threatening complicationof this condition is which?
1. Pneumonia
2
,Pulmonary edema
Pulmonary embolism
Myocardial infarction
Correct Answer: 3. Pulmonary embolism
A 24-year-old man seeks medical attention for complaints of claudication in the
arch of the foot. The nurse also notes superficial thrombophlebitis of the lower leg.
The nurse should check the client forwhich next?
Smoking history
Recent exposure to allergens
History of recent insect bites
Familial tendency toward peripheral vascular diseaseCorrect Answer: 1. Smoking
history
The nurse has reinforced instructions to the client with Raynaud'sdisease about
self-management of the disease process. The nurse determines that the client needs
further teaching if the client states which?
"Smoking cessation is very important."
"Moving to a warmer climate should help."
"Sources of caffeine should be eliminated from the diet."
"Taking nifedipine (Procardia) as prescribed will decrease vesselspasm."
Correct Answer: 2. "Moving to a warmer climate should help."
A client with myocardial infarction suddenly becomes tachycardic,shows signs of
air hunger, and begins coughing frothy, pink-tinged sputum. The nurse listens to
breath sounds, expecting to hear which breath sounds bilaterally?
3
, 1. Rhonchi
2. Crackles
3. Wheezes
Diminished breath soundsCorrect Answer: 2. Crackles
The LPN/LVN is collecting data on a client with a diagnosis of right-sided heart
failure. The nurse should expect to note which specific characteristic of this
condition?
1. Dyspnea
Hacking cough
Dependent edema
Crackles on lung auscultation Correct Answer: 3. Dependent edema
The LPN/LVN is checking the neurovascular status of a client whoreturned to the
surgical nursing unit 4 hours ago after undergoing an aortoiliac bypass graft. The
affected leg is warm, and the nurse notes redness and edema. The pedal pulse is
palpable and unchanged from admission. The nurse interprets that the
neurovascular status is which?
Moderately impaired, and the surgeon should be called
Normal, caused by increased blood flow through the leg
Slightly deteriorating, and should be monitored for another hour
Adequate from an arterial approach, but venous complications arearising
Correct Answer: 2. Normal, caused by increased blood flow through theleg
A client with a diagnosis of rapid rate atrial fibrillation asks the nursewhy the health
care provider is going to perform carotid massage. The LPN/LVN responds that
this procedure may stimulate which?
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