You practice vitals, infection control, documentation, and the first nursing action when a patient is unstable. Five of the 15 questions include the correct answer and rationale. The other ten keep answers in the study hub. Continue with the LPN exams exam guide or more LPN exams practice questions.
Five fundamentals questions with answers
Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
A client is admitted to a day hospital following an episode in which he purchased a gun to use while standing guard over his property to prevent a neighbor from erecting a boundary fence. His wife describes him as distrustful of the motives of others and often interpreting others' motives as threats. She mentions that one time he accused her of having an affair with a neighbor with whom she chatted occasionally. The care plan will list the priority outcome as 'Client will:
A. admit his action was excessive based on the circumstance.
B. write the neighbor a letter of apology.
C. demonstrate trust in the nurse.
D. identify positive role models.'
Show answer and rationale
Correct answer: C — demonstrate trust in the nurse.
The correct answer is C: demonstrate trust in the nurse. This is the priority outcome because the client's lack of trust and tendency to perceive threats need to be addressed first. By demonstrating trust in the nurse, the client can begin to develop a therapeutic relationship, which is essential for addressing his distrustful behavior and interpreting threats. This outcome focuses on building rapport and establishing a foundation for therapeutic interventions.
Choice A is incorrect because admitting his action was excessive may not address the underlying issues of distrust and misinterpretation of motives. Choice B is incorrect as it does not address the client's core issues and may not be appropriate in this context. Choice D is also incorrect as identifying positive role models is not a priority when the client's trust and perception issues need immediate attention.
Question 2
Which of the following statements is true of chest tubes?
A. The drainage system must be kept above the level of the resident's chest.
B. The chest drainage must be observed for amount and color.
C. The tubing should be kinked.
D. Chest tubes will only be in the front of the body
Show answer and rationale
Correct answer: B — The chest drainage must be observed for amount and color.
The correct answer is B: The chest drainage must be observed for amount and color. This statement is true because monitoring the amount and color of chest drainage is crucial in assessing the resident's condition, detecting any signs of bleeding or infection. It helps in determining the effectiveness of the chest tube in removing air or fluid from the pleural space.
Incorrect choices:
A: The drainage system must be kept above the level of the resident's chest - This is incorrect as the drainage system should be kept below the level of the resident's chest to facilitate drainage.
C: The tubing should be kinked - Kinking the tubing can obstruct the flow of drainage, which is harmful.
D: Chest tubes will only be in the front of the body - Chest tubes can be placed in various locations depending on the specific condition being treated, not just in the front of the body.
Question 3
The true leg length should be measured between which of the following points?
A. Greater trochanter to lateral malleolus
B. Umbilicus and lateral malleolus
C. ASIS and medial malleolus
D. Anterior inferior iliac spine and medial malleolus
Show answer and rationale
Correct answer: C — ASIS and medial malleolus
The true leg length should be measured between the ASIS (anterior superior iliac spine) and the medial malleolus. This is because the ASIS is a prominent bony landmark on the pelvis, representing the top of the femur, and the medial malleolus is the bony prominence on the inner side of the ankle, representing the bottom of the tibia. Measuring between these points provides an accurate representation of the actual length of the leg.
Choice A (Greater trochanter to lateral malleolus) is incorrect because the greater trochanter is not the starting point for measuring leg length. Choice B (Umbilicus and lateral malleolus) is incorrect as the umbilicus is not a reliable reference point for leg length measurement. Choice D (Anterior inferior iliac spine and medial malleolus) is incorrect because the AIIS is not typically used as a reference point for leg length measurement.
Question 4
Nosocomial infection implies infection acquired
A. During the course of hospitalization
B. While conveying patient to the hospital
C. From very close relations
D. From a patient's residence
Show answer and rationale
Correct answer: A — During the course of hospitalization
Nosocomial infections, also called hospital-acquired infections, are those contracted by patients during their stay in a healthcare facility, typically after admission. 'During the course of hospitalization,' is correct because it matches this definition, as outlined by the World Health Organization (WHO), where infections emerge 48 hours or more after admission, often from hospital pathogens like MRSA. 'While conveying patient to the hospital,' refers to pre-admission exposure, not nosocomial. 'From very close relations,' suggests community-acquired infection, not hospital-specific. 'From a patient's residence,' also points to pre-hospital sources. The term nosocomial' derives from Greek words meaning hospital-related disease, emphasizing infections tied to healthcare settings, making A the precise answer, rooted in clinical epidemiology's focus on hospital environments.
Question 5
Which finding during an abdominal assessment suggests the presence of ascites?
A. Hyperresonance on percussion.
B. Shifting dullness on percussion.
C. Borborygmi on auscultation.
D. Rebound tenderness on palpation.
Show answer and rationale
Correct answer: B — Shifting dullness on percussion.
The correct answer is B: Shifting dullness on percussion. Ascites is the accumulation of fluid in the peritoneal cavity. When the patient is in a supine position, the fluid settles by gravity and causes dullness upon percussion in the dependent areas. Shifting dullness occurs when the patient is turned to the side, causing the fluid to shift and the dullness to move. This finding is specific to ascites.
A: Hyperresonance on percussion is associated with bowel gas and is typically heard in cases of bowel obstruction.
C: Borborygmi on auscultation refers to hyperactive bowel sounds and is not specific to ascites.
D: Rebound tenderness on palpation indicates peritoneal irritation, often seen in cases of peritonitis, not ascites.
In summary, shifting dullness on percussion is the key finding in assessing ascites due to the movement of fluid in the peritoneal cavity.
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Question 6
Which vital sign is an essential measurement to assess a patient's basic physiological functioning?
A. Pain level
B. Skin color
C. Respiratory rate
D. Dietary preferences
Correct answer:
Respiratory rate is a critical vital sign that reflects how well a patient's body is oxygenating and removing carbon dioxide, key components of basic physiological functioning. It directly indicates the efficiency of the respiratory system, which is essential for life. Pain level, while important for comfort, is subjective and not a direct measure of physiological function. Skin color can provide clues about circulation or oxygenation but is less specific and quantifiable than respiratory rate. Dietary preferences are unrelated to immediate physiological assessment, as they pertain to nutrition rather than real-time bodily function. Nurses monitor respiratory rate to detect distress or deterioration quickly, making it a fundamental metric in patient care. Understanding its significance ensures timely interventions, especially in emergencies where breathing is compromised.
Your adult patient called for help after he began to vomit bright red blood. On arrival, the patient is found to be tachycardic and bleeding freely from his mouth. His respirations are shallow, and his skin is cool with a blood pressure of 68 systolic. His only history involves liver disease from chronic alcoholism. He denies drinking recently. What should be the goal of your pre-hospital intervention with this patient after ensuring his airway and applying oxygen therapy?
A. Fluid resuscitation to maintain a systolic blood pressure of 80-90 systolic
B. Fluid resuscitation to maintain a blood pressure of at least 100 systolic
C. To control the hemorrhage with pharmacologic intervention
D. Maintaining a high blood oxygen saturation to continue perfusion at the cellular level
Correct answer:
The correct answer is A: Fluid resuscitation to maintain a systolic blood pressure of 80-90 systolic. In this scenario, the patient is presenting with signs of hemorrhagic shock, such as tachycardia, hypotension, and cool skin. The primary goal of pre-hospital intervention is to stabilize the patient's hemodynamic status by restoring intravascular volume. The target systolic blood pressure range of 80-90 is appropriate for this situation to ensure adequate tissue perfusion without exacerbating bleeding. Choice B (maintaining a blood pressure of at least 100 systolic) may be too aggressive and risk further bleeding. Choice C (pharmacologic intervention) is not the initial priority in this acute situation. Choice D (maintaining high blood oxygen saturation) is important but not the primary goal; fluid resuscitation takes precedence in hemorrhagic shock to improve perfusion.
The administration at a local medical center examines the trends in health problems when developing long-range plans for staffing and space allocation. Which of the following sources of information would be most helpful?
A. Local data drawn from a professional survey in the city
B. The National Health Interview Survey
C. The National Hospital Discharge Survey
D. The state’s vital statistics
Correct answer:
The correct answer is C: The National Hospital Discharge Survey. This source provides comprehensive data on hospital utilization, including reasons for admission and discharge diagnoses. It offers insights into the specific health problems that require hospitalization, which is crucial for staffing and space allocation planning.
A: Local data drawn from a professional survey in the city - While local data can be valuable, it may not provide a comprehensive overview of health problems that require hospitalization.
B: The National Health Interview Survey - This survey focuses on health behaviors and access to care, rather than specific health problems that lead to hospitalization.
D: The state's vital statistics - While vital statistics provide general health information, they may not offer detailed insights into specific health problems requiring hospitalization.
The nurse is preparing to administer a rectal suppository antipyretic medication. Which action by the nurse is correct?
A. Allowing the suppository to soften at room temperature before inserting
B. Asking the patient to lie on the right side during insertion of the medication
C. Having the patient remain in a side-lying position for at least 5 minutes after insertion
D. Using a lubricant such as petrolatum gel (Vaseline) to lubricate the medication
Correct answer:
Rectal suppositories, like antipyretics, require proper technique to ensure absorption and comfort. Option C is correct because keeping the patient side-lying for at least 5 minutes prevents expulsion and allows the suppository to melt and absorb into the rectal mucosa. Option A is incorrect as softening at room temperature isn't standard; suppositories are designed to melt at body temperature. Option B is wrong because the left side is preferred for anatomical reasons (sigmoid colon alignment), not the right. Option D is incorrect as petrolatum isn't water-soluble and may hinder absorption; a water-soluble lubricant is recommended. The nurse's action in C supports effective delivery and retention of the medication, aligning with best practices for rectal administration to achieve the intended fever-reducing effect while minimizing patient discomfort or procedural errors.
What describes the expanded role of a nurse after specialized training and credentialing?
A. Primary care nurse.
B. Private duty nurse.
C. Clinical nurse specialist.
D. Visiting nurse.
Correct answer:
The correct answer is C, Clinical Nurse Specialist (CNS). A CNS has specialized training and credentialing, allowing them to provide expert clinical care, education, research, and leadership in a specific area of nursing practice. They have advanced knowledge and skills to improve patient outcomes and influence healthcare delivery.
A: A Primary Care Nurse typically provides general healthcare services to a variety of patients.
B: Private Duty Nurse provides one-on-one care to individual patients in their homes.
D: A Visiting Nurse provides care to patients in their homes, but without the specialized training and credentialing of a CNS.
In summary, the expanded role of a nurse with specialized training and credentialing is best represented by a Clinical Nurse Specialist due to their advanced clinical expertise and ability to impact healthcare on a broader scale.
A patient who has heart failure has recently started taking digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril. Which finding by the home health nurse is a priority to communicate to the health care provider?
A. Presence of 1+ to 2+ edema in the feet and ankles
B. Palpable liver edge 2 cm below the ribs on the right side
C. Serum potassium level 3.0 mEq/L after 1 week of therapy
D. Weight increase from 120 pounds to 122 pounds over 3 days
Correct answer:
The correct answer is C. A serum potassium level of 3.0 mEq/L after 1 week of therapy is a priority finding to communicate to the healthcare provider because digoxin, furosemide, and captopril can all cause electrolyte imbalances, especially hypokalemia, which can increase the risk of digoxin toxicity leading to life-threatening dysrhythmias. It is crucial to address and monitor potassium levels closely in patients taking these medications.
A: Presence of 1+ to 2+ edema in the feet and ankles is a common finding in heart failure patients and may not be an immediate concern unless it worsens.
B: Palpable liver edge 2 cm below the ribs may indicate hepatic congestion, which can occur in heart failure, but it is not as urgent as monitoring potassium levels.
D: A weight increase of 2 pounds over 3 days can be a sign of fluid retention, which is important to monitor but
A nurse is caring for a client who is 1 hr postoperative following rhinoplasty. Which of the following manifestations requires immediate action by the nurse?
A. Increase in frequency of swallowing.
B. Moderate sanguineous drainage on the drip pad.
C. Bruising to the face.
D. Absent gag reflex.
Correct answer:
The correct answer is A: Increase in frequency of swallowing. After rhinoplasty, an increase in frequency of swallowing may indicate possible bleeding, which requires immediate action by the nurse. The client could be experiencing postoperative bleeding, and prompt intervention is necessary to prevent complications. Choice B, moderate sanguineous drainage on the drip pad, is expected in the immediate postoperative period and does not require immediate action unless it becomes excessive. Choice C, bruising to the face, is a common postoperative finding and does not require immediate action unless it is excessive or affects the airway. Choice D, absent gag reflex, would not be expected immediately following rhinoplasty and would require intervention, but the manifestation of increased swallowing frequency is a higher priority due to its association with potential bleeding.
A client9s body uses physiologic mechanisms from within to respond to internal changes and maintain an essential balance. This process is known as:
A. stress.
B. homeostasis.
C. self-regulation.
D. fight-or-flight response.
Correct answer:
The correct answer is B: homeostasis. Homeostasis is the body's ability to maintain internal stability and balance in response to changes in the external environment. It involves various physiological mechanisms that regulate temperature, blood pressure, pH levels, and other vital functions. Homeostasis ensures that the body functions optimally and stays within a narrow range of conditions necessary for life.
Choice A, stress, refers to the body's response to external challenges and is not the process of maintaining internal balance. Choice C, self-regulation, is a broader term that can encompass various processes, including homeostasis but does not specifically refer to the maintenance of internal balance. Choice D, fight-or-flight response, is a specific physiological response triggered by perceived threats and is not the same as the overall process of homeostasis.
With regards to starting drug therapy for arterial hypertension, at which level of diastolic pressure should treatment be considered?
A. 60 to 69 mmHg
B. 70 to 79 mmHg
C. 80 to 89 mmHg
D. 90 to 95 mmHg
Correct answer:
Arterial hypertension management follows guidelines like those from the American College of Cardiology, where drug therapy is typically considered when blood pressure exceeds certain thresholds. Diastolic pressure of 90 mmHg or higher is a widely accepted level for initiating treatment in adults, especially if sustained or accompanied by risk factors like diabetes or organ damage, as it indicates stage 1 hypertension needing intervention to prevent cardiovascular complications. Levels below 90 mmHg (60-69, 70-79, 80-89 mmHg) may warrant lifestyle changes but not immediate drug therapy unless systolic pressure or other risks elevate the profile. The 90-95 mmHg range aligns with clinical practice to start antihypertensives, balancing benefit and risk, particularly in primary care settings where family physicians aim to reduce stroke and heart disease incidence effectively.
Which of the following examples demonstrates a holistic approach to care?
A. While Ebony is giving Ms. Potter a bath, she asks her how her day has been and listens carefully.
B. Jim rushes his residents through their meals without talking with them so that they can get their dinner faster.
C. Teresa is very religious and likes to share her religious views with her residents.
D. Lemarcus often spends so much time chatting with his residents that he does not finish all of his work.
Correct answer:
The correct answer is A. This choice demonstrates a holistic approach to care by incorporating physical care (giving a bath) with emotional support (asking about the resident's day and listening). This shows a focus on the resident's overall well-being and not just their physical needs. It acknowledges the importance of the resident's feelings and experiences in addition to their physical health.
Summary of other choices:
B: This choice shows a rushed and impersonal approach to care, focusing solely on completing tasks quickly rather than connecting with the residents.
C: While sharing religious views may provide comfort to some residents, it does not necessarily address their holistic needs and may not be welcomed by all residents.
D: Spending excessive time chatting may neglect important tasks and responsibilities, indicating a lack of balance in care provision.
LPN exams fundamentals practice questions, set 62 for nursing students in the United States. Fifteen items. Five include answers and rationales in American English.
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