LPN exams fundamentals practice questions set 29

Correct answer:

The correct answer is B: Utilize SBAR to notify the primary health care provider. This is the first action the nurse should take because the patient is exhibiting signs of a surgical site infection (redness, purulent drainage, tenderness, elevated temperature, and increased WBC count), which requires immediate attention from the healthcare provider for further evaluation and management. Notifying the provider promptly allows for timely intervention to prevent complications. Choices A, C, and D are incorrect: A: Planning to change the surgical dressing during the shift is not the priority as the patient's symptoms indicate a potential infection that needs immediate attention. C: Reevaluating the temperature and WBC count in 4 hours delays necessary intervention for a suspected infection. D: Checking the solution used for skin preparation in surgery is not urgent compared to notifying the provider about the concerning signs of infection.

Correct answer:

The five rights of medication administration are a foundational framework in nursing to ensure safe and effective drug delivery. These rights focus on verifying that the medication is given to the intended individual, using the prescribed substance, in the appropriate amount, through the proper method, and at the designated time. This systematic checklist helps prevent errors that could harm the patient, such as giving the wrong drug or dose. Other options may include elements relevant to nursing practice, like documentation or teaching, but they deviate from the universally accepted five rights. For instance, teaching is part of patient education, not a core right, and room or storage considerations are logistical, not directly tied to administration. The correct combination emphasizes patient safety and precision, reflecting best practices in healthcare settings and aligning with protocols designed to protect both the patient and the nurse.

Correct answer:

The correct answer is C: Body image disturbance and self-imposed starvation. This is a priority because it directly addresses the core issues of anorexia nervosa and poses immediate risks to the patient's health. Body image disturbance contributes to the patient's self-imposed starvation, which can lead to severe malnutrition and other serious complications. Addressing this issue is crucial for the patient's well-being. A: Weight loss of 2 pounds over the past week is concerning but may not be an immediate priority compared to addressing the underlying psychological issues. B: Denial of the need for nutrition rehabilitation is important to address but may not pose an immediate threat to the patient's health compared to self-imposed starvation. D: Refusal to participate in social activities may be a consequence of anorexia nervosa but does not directly address the urgent need to address body image disturbance and self-imposed starvation.

Correct answer:

Acute Respiratory Distress Syndrome (ARDS) is a life-threatening condition marked by severe hypoxemia and diffuse lung injury, often requiring immediate airway and ventilatory support. The nurse should first anticipate preparing for intubation because ARDS patients typically progress to respiratory failure, necessitating mechanical ventilation to maintain oxygenation and ventilation when lung compliance drops. Oxygen at 5 L/minute via nasal cannula is insufficient for the profound hypoxemia of ARDS, which often requires high-flow oxygen or positive pressure ventilation. Deep suctioning addresses secretions but not the underlying oxygenation failure, and while corticosteroids may be considered later for inflammation, they are not the initial priority. Intubation ensures a secure airway and allows for precise ventilatory management, critical in ARDS where rapid deterioration is common, aligning with emergency protocols to stabilize the patient.

Correct answer:

In a palliative care setting, when caring for a client approaching death with symptoms of shortness of breath and noisy respirations, using a fan can help alleviate the sensation of breathlessness. This intervention can provide comfort by improving air circulation and reducing the perception of breathlessness. Turning the client every 2 hours may not directly address the respiratory distress caused by noisy respirations. Providing supplemental oxygen may not be indicated or effective in all cases, especially in end-of-life care where the focus is on comfort rather than aggressive interventions. Administering diuretics as prescribed would not be appropriate for addressing noisy respirations and shortness of breath in a dying client, as this may not be related to fluid overload or congestion. Therefore, the most appropriate action to help the client feel more comfortable in this situation is to use a fan to reduce the feeling of breathlessness.

Correct answer:

The correct answer is D because prioritizing biochemical assessment in nutritional status appraisal helps predict metabolic abnormalities in nutritional intake. By analyzing blood levels of key nutrients and metabolic markers, the nurse can identify deficiencies or excesses that indicate how well the body is utilizing nutrients. This information can guide interventions to correct imbalances and improve overall health. Choice A is incorrect as it refers to identifying abnormalities in the chemical structure of nutrients, which is not directly related to predicting metabolic abnormalities in nutritional intake. Choice B is incorrect because predicting abnormal utilization of nutrients does not necessarily directly correlate to metabolic abnormalities. Choice C is incorrect as it refers to reflecting the tissue level of a given nutrient, which is not the primary focus when prioritizing biochemical assessment for nutritional status appraisal.

Correct answer:

To measure for leg length discrepancy accurately, you should measure from the Anterior Superior Iliac Spine (ASIS) to the Medial Malleolus. This is because the ASIS is a reliable and consistent bony landmark for measurement, and the medial malleolus is a stable reference point at the ankle joint. Measuring from ASIS to Medial Malleolus ensures that the entire length of the leg is accounted for, providing an accurate assessment of any potential length difference between the two legs. This measurement technique is commonly used in clinical practice and research studies to assess leg length inequality. Summary: A: Incorrect - Does not account for the full length of the leg. B: Incorrect - PSIS is not commonly used as a reference point for leg length measurement. C: Correct - ASIS to Medial Malleolus provides an accurate measurement of leg length discrepancy. D: Incorrect - PSIS is not commonly used for measuring leg length, and measuring

Correct answer:

The correct answer is B: uses autodiagnosis. Autodiagnosis is critical in the nurse-client relationship as it involves self-awareness and reflection by the nurse to understand their own biases, emotions, and reactions. This self-awareness allows the nurse to effectively manage their responses, maintain professionalism, and provide quality care to the client. By being aware of their own thoughts and feelings, nurses can better empathize with the client, build trust, and communicate effectively. This approach helps prevent potential conflicts and misunderstandings, leading to better outcomes in the nurse-client relationship. Summary: A: Developing trust in the client is important but not the most critical measure. C: Relying on the client liking the nurse is not professional and may compromise boundaries. D: Analyzing biologic, familial, and sociocultural factors is important but not as critical as self-awareness through autodiagnosis.

Correct answer:

The correct answer is B: Administer Rh(D) immune globulin (RhoGAM). In this scenario, the patient is Rh negative and her husband is Rh positive, which puts her at risk for Rh isoimmunization. Administration of Rh(D) immune globulin (RhoGAM) helps prevent the mother's immune system from developing antibodies against the Rh-positive fetus's blood, thereby protecting future pregnancies. This intervention is crucial in preventing hemolytic disease of the newborn. Choice A: Obtaining a urinalysis is not indicated in this case as the patient's main concern is her abdominal pain and pregnancy status, not related to her urinalysis. Choice C: Discharging the patient without administering Rh(D) immune globulin would be inappropriate as it puts future pregnancies at risk of complications due to Rh incompatibility. Choice D: Scheduling a follow-up ultrasound is not the immediate next step. Administering Rh(D) immune globulin is the priority to

Correct answer:

Digoxin is a cardiac glycoside used in congestive heart failure to improve heart function. It exerts an inotropic effect, increasing myocardial contractility, which enhances cardiac output and raises blood pressure from a hypotensive state. Simultaneously, it has a negative chronotropic effect, slowing the heart rate by enhancing vagal tone, countering the tachycardia often seen in CHF. Improved cardiac output also reduces respiratory distress by alleviating pulmonary congestion, slightly lowering the respiratory rate. Starting with vital signs of BP 85/50 mm Hg, pulse 96 bpm, and respirations 26 cpm, effective digoxin therapy would show a modest BP increase (e.g., to 98/60 mm Hg), a reduced pulse (e.g., to 80 bpm), and a slight drop in respirations (e.g., to 24 cpm). Extreme changes, like a pulse of 110 bpm or unchanged hypotension, suggest either toxicity or ineffectiveness, making the moderate improvement the expected therapeutic outcome.