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Which of these would be an appropriate assignment for the LPN/LVN?
- A. an 18-year-old femur fracture client who is just returning to the floor from the recovery unit
- B. an 84-year-old client 2 days post-op after knee replacement surgery who needs help ambulating
- C. a 35-year-old client who is suffering from an acute asthma attack
- D. a 20-year-old client with Cystic Fibrosis who needs an early morning sputum sample collection
Correct Answer: D
Rationale: Collecting sputum samples on stable clients are within the scope of practice for an LPN. An RN should do the initial assessment on any client immediately post-op. An RN or medical provider should attend to any client suffering from an acute asthma attack. A client who is medically stable and needs help ambulating is best assigned to a nursing assistant.
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Which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivered to the lab immediately after collection?
- A. Make it a stat delivery.'
- B. Please do it as soon as you can after break.'
- C. This client is delirious, and we're worried about a urinary sepsis.'
- D. Take this client to the bathroom now and collect a urine specimen from this voiding. Take the specimen to the lab immediately.'
Correct Answer: D
Rationale: Effective delegation depends on clear, concise direction that leaves no room for question or interpretation. The specific instruction to collect and deliver immediately ensures the task is prioritized.
When obtaining a health history on a menopausal woman, which information should a nurse recognize as a contraindication for hormone replacement therapy?
- A. family history of stroke
- B. ovaries removed before age 45
- C. frequent hot flashes and/or night sweats
- D. unexplained vaginal bleeding
Correct Answer: D
Rationale: Unexplained vaginal bleeding is a contraindication for hormone replacement therapy. Family history of stroke is not a contraindication for hormone replacement therapy. If the woman herself had a history of stroke or other blood-clotting events, hormone therapy could be contraindicated. Frequent hot flashes and/or night sweats can be relieved by hormone replacement therapy.
An LPN is working on the care plan for a client with diabetes mellitus. Which of these outcomes would be the most appropriate?
- A. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy).
- B. The client will maintain a blood glucose level within normal range limits today.
- C. The client will maintain a blood glucose level within the normal range of 70-110 (per facility policy) throughout my shift.
- D. The client will maintain a blood glucose level within normal limits throughout my shift.
Correct Answer: C
Rationale: Outcomes in nursing care plans should be objective, obtainable, observable, and measurable.
Which of the following is most likely to impact the body image of an infant newly diagnosed with Hemophilia?
- A. immobility
- B. altered growth and development
- C. hemarthrosis
- D. altered family processes
Correct Answer: D
Rationale: Altered Family Processes is a potential nursing diagnosis for the family and client with a new diagnosis of Hemophilia. Infants are aware of how their caregivers respond to their needs. Stresses can have an immediate impact on the infant's development of trust and how others relate to them because of their diagnosis. The long-term effects of hemophilia can include problems related to immobility. Altered growth and development could not have developed in a newly diagnosed client. Hemarthrosis is acute bleeding into a joint space that is characteristic of hemophilia. It does not have an immediate effect on the body image of a newly diagnosed hemophiliac.
The nurse receives an assignment of three clients. Which of the following should the nurse consider as highest priority when determining which client to assess first?
- A. the client who most recently rang their call bell
- B. the client who has been waiting the longest for their call bell to be answered
- C. the client who is in the most pain
- D. the client who may have a risk for an airway obstruction
Correct Answer: D
Rationale: The nurse should use the ABCs (airway, breathing, circulation) to prioritize assessing a client with an airway risk first.