200+ NCLEX-LPN Questions (and Answers)
By Minute Help Guides
© 2011 by Minute Help, Inc.
Published at SmashWords
Disclaimer
These questions are based on the NCLEX examination, but this book is not officially endorsed by the National Council of State Boards of Nursing. The book is meant to help you, but the questions presented here vary from the actual examination. Use at your discretion.
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Management of Care – Management Care LPN
An LPN is caring for a 30-year-old female client who is prescribed with lithium. The client refuses to take the medication and accuses the LPN of trying to poison her. The nurse states, “If you keep on refusing your medication, you are giving us no other choice but to place you in seclusion.” The LPN can be charged with which legal tort?
Slander
Battery
Assault
Libel
Answer: C – The LPN can be charged with assault. Assault is an intentional legal tort that involves unlawful threat to another person, creating a well-founded fear or apprehension of immediate harmful contact. The nurse does not have to touch the client to commit assault. Battery involves intentional and unlawful touching of a client against his or her will. Slander and libel are forms of defamation. Libel refers to defamatory statements that have been made in a fixed medium, like an article in a newspaper or a photo. Slander involves defamatory statements made verbally or in form of bodily gestures.
An LVN/LPN is caring for a female client who is diagnosed with cancer. The client informs the nurse that every time she makes an attempt to ask her physician about her chances of surviving cancer, the physician changes the subject. The client says, “I want to know my chances of getting well but I have too many questions, I do not know where to start.” Which of the responses by the nurse is the most appropriate?
“It might be a good idea to list down your questions before talking to your physician.”
“Ask the physician for clarification, if there is something you do not understand.”
“I am sure you can do it. You just have to be firm and persistent.”
“I know how you feel. Would you like to see your physician as soon as possible?”
Answer: A - The most appropriate response of the nurse is to suggest to the client to list down her questions before seeing the physician. Listing down her questions is a great way to organize the details of information that she would like to know from the physician. This action is also a good way of maintaining focus and allowing the client to remember the details of information that need clarification. Options B and D do not address the client’s concerns. Option C demonstrates false assurance.
A 20-year-old female client is admitted to the facility after her mother found new cuts on her right and left wrists. On admission, the client informs the LPN that she does not need any help and that she is only going through a phase. The client was diagnosed with depression almost a year ago and has been doing well until she was dropped from the swimming team. The client loses which of the following client rights?
The right to wear her own clothes.
The right to be free from locked seclusion and chemical and mechanical restraints.
The right to refuse psychotropic medications and psychotherapy.
The right to leave the facility against medical advice.
Answer: D – The client was involuntary admitted to the facility, losing the right to leave the facility against medical advice until the client poses no danger to self or others. When the client’s mental health condition stabilizes and has successfully appealed a form of involuntary admission, she should be immediately prompted that she is no longer an involuntary client and that she may be allowed to leave the facility, even against medical advice. The client has the right to wear her own clothing and to refuse psychotropic medications or psychotherapy. The client should be free from seclusion and restraints, except when she is a danger to self or others. These restraining methods should only be allowed only after methods of resolution have been unsuccessful.
A nurse is teaching a group of student nurses about advanced directives. Which of the following statements about advance directives is the least accurate?
They do not designate another person to make health care decisions for the client.
They may be changed or canceled at any given time, as long as the client is of sound mind.
They allow the client to appoint someone who can make health care decisions for him or her when the client is unable to do so.
It is based on the person’s right to self-determination.
Answer: A – Advanced directives allow the client to designate another person to make health care decisions for him or her when he or she is unable to express them. There are three main types of advance directives: living will, durable power of attorney and do not resuscitate order. The durable power of attorney allows the client to designate another person to make decisions about health care when he or she is not able to do so. The other options are accurate.
An alert female client with stage 4 breast cancer informed the LVN/LPN that she wishes to leave the facility as soon as possible, against medical advice. The occurrence of complications is likely. Before discharge, the LVN/LPN should reinforce that:
The client may need to search for another facility, if complications occur.
The client is aware of the possible risks and complications.
The ethics committee should be informed about the client’s decision.
The client’s next of kin in consulted in private to dissuade the client from leaving the facility.
Answer: B – Before discharge, the nurse should ensure that the client is aware that the occurrence of complications is likely. The client may come back to the facility any time she needs medical help. Informing the ethics committee about the client’s decision is unnecessary. The client is mentally alert. The nurse may only talk to the client’s next of kin if the client is mentally or physically incapacitated.
An LVN/LPN in a pediatric unit is assigned to care for an 8-month-old child with Wilm’s tumor. The nurse can be charged with negligence if which of the following actions is done during a massage?
The nurse’s strokes are kept firm.
The nurse massages the baby’s extremities, head, abdomen and back for 15 minutes.
The child is placed on a supine position, with the head propped on a pillow.
The nurse uses downward strokes to calm the child.
Answer: B – The nurse should not massage the child’s abdomen if the child is diagnosed with a Wilm’s tumor. Abdominal massage may cause dissemination of cancer cells. The strokes should be kept firm. Placing the child on a supine position, with the head propped on a pillow allows the nurse to see the child’s expressions during the massage. Downward strokes cause calming effects, whereas upward strokes are stimulating.
A nursing team consists of a registered nurse, LVN/LPN and nursing assistant. Which of the following clients in the unit is properly assigned to the LVN/LPN?
A 30-year-old female client who requires assistance during ambulation.
A 75-year-old male client with stasis ulcers in both extremities, requiring a dressing change.
A 35-year-old obese, diabetic client who is for discharge.
An 18-year-old male client with a casted left leg, requesting assistance to use the urinal.
Answer: B – A client who requires a dressing change is properly assigned to the LVN/LPN. An LVN/LPN may be assigned to care for clients who are stable with expected outcomes. Aseptic procedures at bedside may be assigned to LVNs. Stable clients who require assistance during ambulation or personal hygiene care are assigned to the nursing assistant. An RN is the appropriate caregiver during before discharge as assessment is necessary.
An LVN/LPN is caring for a male client who is admitted due to alcohol intoxication. The nurse writes down the following on the client’s chart: “The client is a drunkard with unresolved emotional issues. He is an immature brat who kept on asking for unnecessary favors from the staff.” The nurse may be charged with which legal tort?
Libel
Slander
Intentional infliction of emotional distress
Battery
Answer: A - The nurse may be charged with libel, which is defined as intentional defamation of a client made in written or printed words or pictures. It intentionally injures the character or reputation of the client who is the subject of written statements. Although the patient is addicted to alcohol, the information entered by the nurse does not have a valid basis. Slander is another form of intentional defamation through spoken words. Intentional infliction of emotional distress is brought against an individual who deliberately acts in a manner that is designed to cause another person severe emotional anguish. Battery involves intentional and unlawful touching of a client against his or her will.
A certified LVN/LPN is attending the unit’s orientation for the new nursing staff. The newly hired nurse would like to determine the standards of care of the institution. The nurse should be advised to refer to which of the following sources:
Organizational chart
Personnel policies
Policies and procedures manual
ICN Code of Ethics for Nurses
Answer: C – The LVN/LPN should refer to the policies and procedures manual to define the standards of care of the institution. Organizational chart focuses on the structural relationship of one medical facility department with another. The Code of Ethics for Nurses functions as a guide when making decisions on ethical issues.
A 35-year-old female client with chronic epilepsy is a participant in a clinical trial of a new drug. The LPN/LVN understands that which of the following rights is not included in the basic rights of a client participating in a clinical study?
Right to full disclosure
Right to confidentiality
Right not to be harmed
Right to withdraw
Answer: C - The right not to be harmed is not included in the basic rights of a client participating in a clinical study. The client’s right to confidentiality, full disclosure, and right to withdraw from the clinical study should be upheld at all times. The right to be harmed is more appropriate in a clinical setting, such as in the adult ward.
An LVN/LPN is providing care to a married 25-year-old female who is at 28 weeks’ gestation. The nurse notices multiple bruises, at varying stages of healing, on the client’s upper arms, thighs and back. The client immediately says, “I had a slip a few days back. It sure is difficult to carry all the weight when pregnant.” The initial response of the nurse is:
“It appears like your husband is physically hurting you. Would you like to talk about it?”
“I will give you a list of numbers of local shelters and safe houses for battered wives.”
“Would you like to tell me what happened before and after you slipped?”
“I will document these findings and talk to your husband afterward.”
Answer: C – The nurse should ask more questions about the mechanism of injury and be objective about the findings. Asking these questions can help the nurse determine whether or not the mechanism of injury is consistent with the physical signs and symptoms. The LPN should then accurately and thoroughly document the findings. Options A and B are appropriate but they are not the initial responses. Women who are suspected to be victims of abuse should be appropriately counseled, especially on creating a safety plan.
A female client with advanced cancer of the liver has decided not to obtain further treatments. The daughter, who is the next of kin, resists the client’s decision. The client’s is alert and awake. Despite the advancement of cancer, the client’s state of mind is stable and clear. The LVN/LPN supports the client’s decision, recognizing the client’s right to self-determination. This morality is based on which theory?
Deontological theory
Caring theory
Theological theory
None of the above
Answer: A - Based on the situation, the nurse’s decision to support the client’s decision to refuse further treatments is derived from deontological theory. A nurse who uses deontological theory bases his or her decision based on the “universal” guidelines. To put simply, the nurse based her decision on what she considers are morally right in this case. A nurse who utilizes theological theory bases his or her decision and actions in accordance to what is right or wrong arising from a belief to a Divine source or a higher Being. A nurse utilizing the caring theory bases his or her decisions and actions according to the relationship between the nurse and client. This theory is based on a belief that a client, as a person, should be treated and managed as a holistic being.
A 75-year-old female client was admitted to the facility due to severe headaches. After the diagnostic work-ups were done and evaluated, the physician found out the client has brain cancer. The physician informed the nursing staff to withhold the information from the client as it was requested by the family members. The client asks the LVN/LPN if she has cancer. Which of the following is the most appropriate response of the nurse?
“I am sorry. I am not aware of the results of the tests.”
“Your physician believes you have cancer, but the diagnosis is not conclusive. I’ll have him speak to you as soon as possible.”
“I feel that it is much better if you ask your family of the diagnosis.”
“I will contact your physician and have him talk to you as soon as possible.”
Answer: D – The most appropriate action of the nurse is to tell the client that her physician will be contacted to see her as soon as possible. This action does not violate the responsibility of the nurse to the client and to the physician and that is to maintain veracity and fidelity, respectively. The physician is mainly responsible in providing the details of information about the diagnosis and is in the best position to provide the best treatment options for the client. The client’s family members are not responsible for informing the client of the diagnosis.
An LPN/LVN assigned in the intensive care unit is approached by a woman who is asking about the condition of a client who was admitted a day ago after falling from a 2-storey building. The client is in coma. To avoid violation of the HIPPA, which of the following actions should the nurse do first before giving out information about the client?
Ask the person to present her identification card, and then check if she is listed as the next of kin.
Ask the inquiring person about the client’s name.
Ask the person for her name and how she is related to the client.
Ask the person for the client’s personal identification number.
Answer: D – The nurse should ask the inquiring person for the client’s personal identification number. In accordance to HIPPA laws, an individual who is seeking information about a client’s condition must first present the client’s PIN. The client is in coma in this case, and so the nurse should ensure that the client’s privacy is protected at all times. Knowing the name of the inquiring individual or her relationship with the client does not authorize information to be distributed.
A group of nurses is required to attend an in-service training session after the facility acquired a new set of clinical equipment. Which of the following is the primary purpose of the in-service training session?
To obtain continuing education credits for license renewal.
To aid reimbursement for client care.
To maintain patient safety.
To meet the requirements set by JCAHO.
Answer: C – With the introduction of new equipment, the facility has to ensure that the staff is adequately trained to maintain patient safety at all times. Using new clinical equipment without training can harm the client and may increase the risk of complications and life-threatening conditions. Medicaid does not require nurses to attend in-service training sessions before reimbursements for client care are given. Not all in-service training sessions are accredited for continuing education credits. JCAHO requires facilities and their staff to be knowledgeable about the use equipment but it is not the primary purpose of the in-service training session.
An LVN/LPN is caring for a postpartum client, who gave birth 24 hours earlier. The client, who is a celebrity, has HIV and is under close monitoring. Which of the following actions of the nurse respect the client’s right to privacy?
Informing another nurse in the unit in-charge of another client to be cautious if she is ever assigned to the client because of an incurable virus.
Photographing the client in her room without consent.
Practicing universal precautions when caring for the client.
Closing the door of the client’s room before providing perineal care.
Answer: D – Closing the door of the client’s room before providing perineal care demonstrates respect to privacy. Options A and B demonstrates violation of this right. The nurse should not give out information to members of staff who are not involved in providing care for the postpartal client. Taking pictures without consent is also a violation. Practicing universal precautions demonstrates infection control; it does not exhibit respect to the client’s right to privacy.
An LVN/LPN is providing morning care to a female client when the client says, “I am not going to have my treatment today.” The client is diagnosed with myeloma and is scheduled to undergo chemotherapy at 10 in the morning. Which of the following is the most appropriate response of the nurse?
“I know it is tiring, but you have to follow the scheduled therapy to feel better again.”
“We cannot force you to have the treatment if you do not want to. I will inform your physician about it.”
“What has occurred to make you refuse your chemotherapy this morning?”
“The team respects your wishes. I will inform the chemotherapy nurse that you do not want to have chemotherapy this morning.”
Answer: C – Although the nurse has to recognize that every client has the right to refuse treatment, the nurse should also determine what has occurred to make the client refuse the chemotherapy. The client may not be feeling well or is probably frustrated about the most recent effects of the therapy. These concerns should be appropriately addressed. Option A discounts the feelings of the client. Although Options A and B showed that the nurse respected the client’s right to refuse treatment, it does not address the client’s, which may have a significant effect on the outcome of the therapy.
An LPN is caring for a 25-year-old client who gave birth to a 7.5-pound baby girl 24 hours ago. On examination, the client is excessively bleeding. The physician orders packed RBCs to be administered immediately. The client informs the LVN/LPN that a blood transfusion is against her religion and that she is refusing this treatment. The nurse does not administer the ordered treatment based on what ethical principle?
Dignity
Autonomy
Veracity
Right to privacy
Answer: B – The nurse does not administer the ordered therapy based on autonomy, which is the right to self-determination. This ethical principle involves the right of the client to make health care decisions for himself or herself. Autonomy is only lost when the client is not physically and mentally capable to make sound decisions for himself or herself. Dignity refers to the client’s right to be managed with courtesy. It also involves client’s right to privacy, which has to be respected at all times. Client’s right to veracity involves honesty and truth by the nurse. The other options are not correct.
In a facility’s neurology unit, each member of the nursing staff is designated to perform specific tasks. The RNs are tasked to administer IV medications, conduct admission assessments and perform discharge assessments. The LPNs are tasked to administer tube feedings, tracheal suctioning and perform sterile dressing changes. Nursing assistants are tasked to assist clients who are in need of help during ambulation, to turn clients every 2 hours and to provide personal hygiene care. Which of the following methods of nursing care delivery is being utilized by the nursing staff?
Case management
Primary nursing
Team nursing
Functional nursing
Answer: D – The nursing staff is utilizing functional nursing. This method of nursing care delivery designates specific people to perform specific tasks to promote efficiency of staff members while a significant amount of work is completed within a short period of time. However, this method has a setback. It causes fragmentation of care and increases the risk of miscommunication among the staff members and between the staff and clients. In team nursing, an RN is in charge of leading a group of health care providers from different disciplines. Client care is coordinated and continuous. In primary nursing, only one nurse is in charge and accountable for the care of a client during his or her hospital stay.
Complete documentation is necessary to promote continuity of care and to improve the quality of nursing care. An LVN/LPN documents the activities done during the shift. Which of the following best demonstrates complete documentation?
9:00AM: Urine output volume is 20 ml; referred to RN accordingly.
8:00AM: Soaked dressing over the catheter site; wound check and change of the dressing performed.
8:00AM: Oral temperature of 100.8 °F, administered Tylenol 500mg PO.
8:00AM: Administered 30 units of Humalog insulin SC.
Answer: C - The entry that best demonstrates complete documentation is: oral temperature of 100.8°F, administered paracetamol 500 mg PO. Assessment finding includes the route and scale of the temperature, and the nursing action includes the name of the drug, the route and dose. Option A is not complete; the nurse should have indicated the volume of urine drained, based on a given time frame. Is it 20 mL for within the last hour, or within the last 2 hours? Option B is not complete; the nurse should have indicated the appearance of the dressing and the characteristics of the drained fluid. Is it soaked with bright red blood? Is it foul in odor? Option D is not complete, the nurse should have indicated the site of insulin administration.
A nursing shortage is expected to grow to as high as 260,000 in 10 to 15 years. Without a well-established program that aims to address this growing concern, resources would be insufficient to support every client who is in need of medical and nursing care. Which of the following is the potential ethical issue involved in nursing shortage?
Fidelity
Beneficence
Justice
Autonomy
Answer: C - The potential ethical issue involved in this case is justice, which refers to equal distribution of scarce resources. Insufficient number of nurses in the workforce would certainly lead to scarcity of health care providers who can support the need of medical and nursing care of anyone who needs it. Fidelity refers to faithful devotion to duty. Beneficence refers to actions that bring benefits to others. Autonomy is the right to self-determination.
An 80-year-old male patient, a Chinese immigrant, says, “The hospital food is too bland. I would certainly want to eat a genuine Chinese food.” The client has no dietary restrictions. As the client’s advocate, what is the best action of the LPN/LVN nurse?
Suggest that the client plan a menu with the nutritionist.
Courteously inform the client that he must eat the foods served in the unit.
Encourage the client’s family members to bring in foods that the patient may like.
Suggest to the dietician to have the kitchen cook Chinese food for the client.
Answer: C - The most appropriate action of the LPN is to encourage the client’s family to bring in foods that the client may like. If the client is not under a dietary program, the client should be encouraged to eat nutritious foods of his or her liking. This action also facilitates social interaction among family members. The other options may be considered, but for clients of ethnic origin who are looking for genuine dishes option C is the best choice.
A 13-year-old female client gave birth to a healthy baby girl 72 hours earlier. The client is to be discharged from the facility. The LVN/LPN agrees with RN when the client is most appropriately referred to which of the following agencies:
Adoption agency
A livelihood program
An agency that provides maternal-infant home care services
A day care center
Answer: C – The client is appropriately referred to an agency that provides maternal-infant care services. This type of agency educates mothers about postpartal care and newborn care, aiming to promote health and wellness of both the mother and child. It informs the mother about the different resources of care that she and her child can avail of in the community. There is no indication that the mother is considering adoption. A livelihood program is not necessary at this time. A day care center may be considered but the need to educate young and new mothers about newborn and postpartal care is a priority.
An LVN/LPN is tasked by the registered nurse to obtain a client's blood glucose level every hour. The client has a history of type 2 diabetes and is admitted due to diabetic ketoacidosis. The nurse is accountable for the following actions except:
Timely and accurate feedbacks.
Obtaining of blood glucose levels every hour.
Documentation of the blood glucose levels.
Actions of the registered nurse during periods of hypoglycemia.
Answer: D – The LVN/LPN is not accountable to the actions of the registered nurse during periods of hypoglycemia. The LVN/LPN is accountable to make timely feedback, obtain blood glucose levels every hour and documentation. To be more concise, the LVN/LPN is accountable for his or her own actions or for the tasks that were delegated by the RN. He or she is not accountable for the actions of the delegator.
A woman came to visit her mother-in-law who had a total hip replacement. As she was walking toward the bathroom, the visitor slipped and fell. The LVN/LPN comes into the room, finding the woman lying on the floor and complaining of severe pain in the back. After an initial assessment, cold packs were applied to the back. Dr. Williams has been notified as well. The following information is documented by the LVN/LPN in the incident report except:
Cold applications were applied to the back.
The woman complained of severe pain in the back, rated 8/10.
The woman slipped and fell onto the floor, and then complained of severe pain in the back.
Dr. Williams was notified about the woman’s complaints.
Answer: C – The LVN/LPN should not document that the client slipped and fell onto the floor, as the nurse has not witnessed the actual event. The nurse found the woman lying on the floor, but the mechanism of injury was not witnessed. An incident report must contain factual information. The nurse should only indicate what was observed or witnessed. The incident report should contain the care given to the woman, the date and time that the woman was first seen by the nurse lying on the floor, the assessment findings and the name of the physician notified.
An 83-year-old female client is admitted to the facility after slipping and breaking the right forearm. Before discharge, the client says, “My daughter has been asking me to write my living will. What is it all about?” Which of the following statements made by the LVN/LPN is the most appropriate?
"It is a document where you can express the treatments which you want to receive or not to receive, only with the assistance of a lawyer."
"It is a document where you can list down your instructions to your surrogate decision-maker."
"It is a document designating who can make health care decisions for you when you are no longer physically or mentally sound to make your own decisions."
"It is a document that allows you to state your preferences about the use of life-sustaining measures, just in case you are not physically or mentally able to do so."
Answer: D – A living will allows the client to state his or her preferences about the use of life-sustaining measures, in case he or she is not physically or mentally able to do so. A client may create his or her living will without the assistance of a lawyer. Options B and C refer to durable power of attorney. The living will and durable power of attorney are types of advance directives.
An LVN/LPN is teaching a group of student nurses about advance directives. Before closing the teaching session, the nurse asked a few questions for evaluation. Which of the following statements made by one of the students indicates that the teaching has been successful?
“The client's physician is mainly responsible in interpreting and implementing advance directives."”
“Advance directives can only be recognized if they are written with the assistance of a lawyer.”
“Advance directives are transferrable from state to state.”
“Living wills and durable powers of attorney are different from advanced directive.”
Answer: A – The physician is mainly responsible in interpreting and implementing advance directives. The physician has the knowledge and skill to determine whether or not the client is physically and mentally sound to make decisions for himself or herself. If the physician believes that the client is physically or mentally incapacitated or if the client has a slim or no chance of recovery, advance directives can be taken into full effect. Advance directives may be written without the assistance of a lawyer. They are not transferrable from state to state. Living wills and durable power of attorney are types of advance directives.
The nursing team consists of an RN, LVN/LPN and nursing assistant. An LVN/LPN in maternal care unit has just received the client assignment for the shift. Which of the following clients is the least appropriately assigned to the LVN/LPN?
An 18-year-old postpartum client who soaked her sanitary napkins every 2 hours.
A 20-year-old postpartum client with a fundus above the umbilicus, which is positioned to the right.
A 48-year-old who complains of abdominal cramps during breastfeeding.
A 20-year-old who had a temperature of 100.2°F for the past 12 hours.
Answer: A – It is not appropriate to assign the LVN/LPN to a postpartum client who is demonstrating signs of postpartum hemorrhage. Soaking up a sanitary napkin every 2 signs is an indicator. The client is unstable with unpredictable outcomes. A fundus positioned to the right indicates that the client should be encouraged to empty urine. Abdominal cramping during breastfeeding is an expected outcome. A slight elevation of temperature is expected after birth. A temperature above 100.4°F needs immediate medical help as it indicates postpartum infection.
The RN is delegating tasks for LVN/LPN and nursing assistants. Which of the following tasks is most appropriately assigned to the LVN/LPN?
Administer morphine sulfate IM to a female client with second-degree burns in the posterior part of the body.
Obtain informed consent from a client who is scheduled for escharotomy.
Create a plan of care that focuses on dietary modifications during recovery.
Monitor a client’s intake and output.
Answer: A – Administering morphine sulfate IM is within the scope of care of LVN/LPN. Obtaining informed consent and creating a plan of care are more appropriately performed by the RN. Monitoring a client’s intake and output is appropriately assigned to the nursing assistants.
A female client is admitted to the unit due to diarrhea and generalized weakness. The client’s boyfriend came for a visit. The LVN/LPN noted that it was past visiting hours and told the visitor about the facility’s rule of no visitors after 8:00 pm. The friend refuses to leave the client's room, insisting that he can still stay past 8:00 pm. The client's visitor can be charged with which legal tort:
Assault
Battery
False imprisonment
Trespass to land
Answer: D – The client’s visitor can be charged with trespass to land. Trespass to land, considered an intentional tort or a negligent act, can be filed against any person who refuses to leave a restricted place or property. Facilities or hospitals allow clients to receive visitors to promote overall well-being, but the visitors and the clients themselves should respect the rules implemented.
Safety
An 83-year-old male elderly had a right hip replacement. The LVN/LPN is tasked by the registered nurse to ensure that the client is properly positioned at all times to prevent dislocation of the prosthesis. The LVN/LPN understands that the following movements should be avoided except:
Internal rotation of the right hip
Hip flexion greater than 90-degrees
Abduction of the right hip
Adduction of the right hip
Answer: C – After a hip replacement, hip abduction may be facilitated by placing pillows between the legs. Abduction will prevent dislocation of prosthesis. Internal rotation of the hip, hip flexion greater than 90-degrees and adduction of the right hip can all increase the risk of dislocation. These movements can be avoided by sitting without crossing legs and using an elevated toilet seat.
A teen-age boy was admitted to the facility after getting involved in a car accident, sustaining multiple fractures, chest contusion and head trauma. The boy complained of headache and chest pain that radiates from his chest to his left arm. The LVN/LPN expects the following treatments or interventions for the client except:
Administration of sublingual nitroglycerine
Administration of oxygen, 5 L/minute
Placing the client’s head of bed at 45-degrees
Starting an IV; open rate
Answer: A – Administration of nitroglycerines is contraindicated. This medication is a bronchodilator and may increase the client’s intracranial pressure. The other interventions are appropriate interventions.
An LVN/LPN is delegated to insert an indwelling catheter to an elderly male client with benign prostatic hyperplasia. When getting ready for insertion, the nurse notices that the bag is not completely sealed. Which of the following actions by the nurse is the best?
Use the bag, using strict aseptic technique.
Inform the registered nurse.
Ask everyone in the unit if the bag has been touched.
Dispose of the bag.
Answer: D – The best action of the nurse is to dispose of the bag and use another bag for the client. If the bag is not completely sealed, the nurse should consider it unsterile. The insertion of indwelling catheter requires the use of strict aseptic technique to prevent contaminants and other bacteria from gaining access to the genito-urinary tract.
A client complains of nausea and vomiting, muscle weakness and abdominal pain. On initial assessment, the nurse notes that the client has yellowing of skin and sclera. The client is diagnosed with hepatitis A infection. The LVN/LPN would expect the RN to implement which type of precautions?
Standard precautions
Contact precautions
Droplet precautions
Airborne precautions
Answer: A – The client will be managed using standard precautions. Standard precautions are used to reduce the risk of transmitting contaminated bodily fluids from one person to another. Hepatitis A is spread through fecal-oral route, so standard precautions are the most appropriate.
An LVN/LPN is assigned to move a client from the client’s bed to the stretcher. The nurse understands that the use of which of the following materials can safely and effectively help the transfer, without consuming much energy.
Footboard
Trapeze bar
Pull sheet
Wheel chair
Answer: C – Utilization of pull sheet will help the team lift the client from the client’s bed to a stretcher. A footboard is used to prevent foot drops. A trapeze bar can be used by the client to help him or her pull himself or herself up in bed. A wheel chair is incorrect.
An LVN/LPN is caring for a post-right hip replacement client. The physician orders axillary crutches to the client during the period of recovery. When descending the stairs using the crutches, which of the following actions would the client do first?
Transfer body weight to the left leg.
Place the crutches on the first stair
Move the left leg forward.
Transfer weight to crutches.
Answer: C – The first action of the client is to transfer his or her weight to the unaffected leg, which is the left leg in this case. The client should then place the crutches on the first stair, transfer weight to the crutches, and move the affected leg forward. The last step is to move the unaffected leg forward. When going down the stairs, the client should keep in mind to make a step using the good leg first.
An LVN/LPN is tasked by the registered nurse to transfer a male client from the bed to the wheelchair and to transport the client to the MRI unit. Which of the following safety measures should the nurse need to keep in mind when performing the task?
As the client gets into the wheelchair, the footplates should be kept in place.
The nurse should push the wheelchair in a forward direction when getting on the elevator.
The nurse should ensure that the wheels are locked before transferring the client.
A and C
Answer: C – The nurse should make sure that the wheels are locked before transferring the client. This action ensures that the wheelchair is stable, avoiding falls during the transfer. The footplates should be removed. The nurse should push the wheelchair in a backward direction when getting on the elevator.
An LVN/LPN is caring for a 12-year-old child who is diagnosed with tumor in the cerebellum. A surgery is scheduled to have the tumor removed. While providing care before the surgery, which of the following actions of the nurse receives the highest priority?
Measure the child’s head circumference on the same time and location every day.
Implement falls precautions.
Monitor the child’s body temperature.
Implement seizures precautions.
Answer: B – The priority action of the nurse is to implement falls precautions. A tumor in the cerebellum causes ataxia, which is characterized by lack of coordination when performing voluntary body movements. Seizures are a late sign of cerebellum tumor. The child’s sutures have closed completely by 12 years, so measuring the child’s head circumference is not necessary. Temperature is not affected by a tumor in the cerebellum.
A 50-year-old female client diagnosed with cancer of the breast was admitted to the facility for another session of chemotherapy. The client’s most recent white blood cell count is 2,500 cells/mm3. The following nursing interventions performed by the LVN/LPN are appropriate for the client except:
Eliminating fresh flowers from the client’s room.
Client is served with cooked fruits and vegetables.
Fresh fruits bought by a visitor are allowed to be placed in the client’s room.
Client is placed in contact isolation.
Answer. D - The client should be placed in protective isolation, not in contact precautions. Fresh flowers release toxins that may provide as good breeding grounds for bacterial growth. The client should be served with cooked fruits and vegetable to ensure that the organisms are eliminated. Fresh fruits may be placed inside the client’s room, rotting fruits are not allowed.
A 20-year-old client comes to the facility complaining of diarrhea, severe muscle weakness and difficulty swallowing. Based on the laboratory tests conducted, the client is infected with Clostridium difficile. The LVN/LPN caring for the client reinforces which type of precautions?
Standard precautions
Contact precautions
Droplet precautions
Airborne precautions
Answer: B – The nurse should reinforce contact precautions when caring for a client with C. difficile infection. Contact precautions are implemented when the causative agent is easily transmitted through direct contact. The other options are correct.
A client was admitted to the facility due to vomiting and diarrhea. The client is diagnosed with a gastrointestinal infection and placed on contact precautions. An LVN/LPN assigned to care for the client is following the implemented form of precaution by demonstrating the following actions except:
The nurse wears clean gloves when providing bed bath to the client.
The nurse suggests to the RN to place the client in a room with a client who is also infected with C. difficile.
The nurse wears protective barriers during perineal care.
The nurse wears clean gloves when taking the client’s blood pressure.
Answer: D – The nurse does not wear clean gloves when taking the client’s blood pressure. C. difficile is transmitted through the oral-fecal route. The risk of contacting the organism when taking the BP is low. Wearing gloves may not be therapeutic as well. The client may be placed in a room with another client who is infected with the same organism.
A 25-year-old client at 35 weeks’ gestation has an outbreak of genital herpes. The client is anxious about transmitting the virus to her child. The client asks the LVN/LPN “How will the infection affect my labor and delivery?” Which of the following actions by the nurse is the most appropriate?
“Your child will need to be prescribed with antibiotics after the delivery.”
“You will be administered with antibiotics when you go in labor.”
“You will most likely have a cesarean delivery.”
“Your physician will prescribe you with antibiotics during the postpartum period.”
Answer: C – The most appropriate response of the nurse is to inform the client that she would probably deliver through a cesarean section. Antibiotics will not be provided. Genital herpes is a viral infection. Antibiotics do not work against viral infections.
An LVN/LPN is in charge of providing care for four clients in the units. All four clients were admitted due to a communicable infection. The nurse reviews the clients’ charts to determine if there are any precautions implemented for the assigned clients. After going through the charts, the nurse reinforces droplet precautions for the following clients:
A client with fever and nuchal rigidity.
A client with salmonellosis.
A client with impetigo.
A client with small, fluid-filled blister-like rash.
Answer: A – A client with fever and nuchal rigidity should be maintained on droplet precautions. The client demonstrates signs of meningitis. Option B and C require contact precautions. The small, fluid-filled blister-like rash is commonly seen in clients with chicken pox, which is controlled by airborne precautions.
An LVN/LPN is caring for a 50-year-old female client has a BMI of 32. The client complained of belching, chest pain and heartburn. The client is diagnosed with hiatal hernia. After meals, the nurse places the client in which of the following positions?
Upright position for at least 30 minutes.
Left side-lying position for at least an hour.
Supine position, flat on bed.
Trendelenburg position for at least an hour.
Answer: A – The client should be placed in the upright position for at least 30 minutes to relieve or prevent heartburn. Lying flat on the bed can cause or aggravate the heartburn. Trendelenburg is more appropriate for hypotensive clients. Left side-lying is more appropriate for pregnant clients, especially during the third trimester. Hiatal hernia is more common in women than in men. Its occurrence is more common in obese, pregnant and elderly clients.
A female client was admitted due to depression. The client attempted twice in the past 2 years. After a week of therapy with antidepressants, the client approaches the LVN/LPN and says, “I feel a lot better now. I am ready to deal with anything.” Which of the following actions of the nurse is the most appropriate?
Suggest to the RN to lower the dose of antidepressants.
Suggest activities that would encourage the client to be a decision-maker.
Reinforce suicide precautions.
Document the findings.
Answer: C – The most appropriate action of the nurse is to reinforce suicide precautions. The nurse should recognize the fact that antidepressants take effect around 3 to 4 weeks after the initiation of therapy. A client cannot achieve dramatic improvement in less than a week. Once the client demonstrates increased energy, there is a greater chance that he or she can carry out actions that may harm herself. Although autonomy should be reinforced, depressed clients are not capable of making their own decisions at this time. The nurse should instead implement activities that would help the client develop her problem solving skills.
An LVN/LPN is delegated to monitor and care for a post-laminectomy client who is recently received from the postanesthesia unit. To keep the client safe during the immediate post-operative period, the nurse keeps in mind to avoid which of the following nursing actions?
Encouraging the client to use the trapeze.
Placing a pillow under the client’s head with the knees slightly flexed.
Turning the client through log rolling technique.
Increasing the client’s intake of whole grains.
Answer: A – The nurse should discourage the client from using an overhead trapeze when lifting up from the bed. Use of overhead trapeze after a laminectomy encourages misalignment of the spine. Options B and C maintain the spine in neutral position. Opioids are administered after the surgery to relieve pain. This increases the client’s risk of constipation, which should be avoided as increased colon volume applies pressure on the spine, resulting in back pain. Whole grains are rich in fiber, which prevents constipation.
An LVN/LPN is tasked to care for a 50-year-old male diabetic client who is scheduled for a below-the-knee amputation surgery. The nurse reviews the proper guidelines of stump care. Which of the following nursing interventions is the most appropriate during the first 24 hours of the postoperative period?
The foot of the bed is elevated during the first 24 hours.
A pillow is placed under the stump during the first 24 hours.
Place a tracheostomy set at bedside.
Position the client in prone position during the first 24 hours.
Answer: A – The most appropriate action during the first 24 hours is elevating the foot of the bed. Elevating the foot of bed can minimize edema. The stump itself should not be elevated. Placing a pillow under the stump during the first 24 hours may cause contracture of hip joint. The client may be placed in prone position in 48 hours.
An LVN/LPN is caring for a diabetic female client who was admitted to the unit after complaining of weakness and headache. The client is diagnosed with ischemic stroke. The client developed right-sided paralysis, as manifested by weakness on the right side of the face, right arm and right leg. Which of the following actions of the nurse is the most appropriate when providing care?
The client’s objects are placed on the right side.
The client’s objects are placed at bedside that is within her reach.
The nurse approaches the client from the right side.
The nurse assists the client in performing range of motion exercises of the right leg and arm.
Answer: D – The nurse would assist the client in performing range of motion exercises of the right leg and arm. The left side of the body is maintained by performing muscle-strengthening exercises. The client’s objects should be placed within her reach on the unaffected side, or the left side in this case. The nurse should approach the client from the left side.
A female LVN/LPN caring for a male client with HIV accidentally pricked one of her fingers with a needle when she was drawing blood from a client. The nurse informs the nurse supervisor about the incident, and proper interventions were immediately performed. The nurse understands that she has to test for HIV contamination due to the needle stick:
6 months after the needlestick.
Immediately and 2 months after the needlestick.
Immediately and 6 months after the needle stick.
Immediately and 3 months after the needlestick.
Answer: D – The nurse has to test for HIV infection immediately after the needle stick and in 3 months after the incident. The test has to be done immediately to determine if she has a pre-existing HIV infection. Seroconversion occurs within 3 months, so she has to get tested again to determine if the needle stick incident caused the HIV.
An LVN/LPN is delegated to care for a newly admitted client with myasthenia gravis. Because the nurse understands the risks and complications associated with the disorder, the nurse knows that it is vital to place which medical equipment at bedside?
Tourniquet
Oxygen
Suction equipment
Incentive spirometry
Answer: B – It is vital to place suction equipment at bedside. A client with myasthenia gravis has a considerable level of muscle weakness throughout the body, including the diaphragm. Weakness of the diaphragm increases the client’s risk for respiratory distress. An intubation tray and an Ambubag are also kept at the client’s bedside. Tourniquet is placed at the bedside of a client who had an amputation. The other options are not a priority.
An LVN/LPN in the pediatrics unit is tasked to care for a 12-year-old child who has a history of tonic-clonic seizures. When the nurse enters the client’s room, the nurse finds the child having seizures in the tonic phase. Which of the following actions by the nurse is the most appropriate?
Insert a padded tongue blade.
Assist the RN administer midazolam IV.
Hold the child still.
Turn the client on one side.
Answer: D – The nurse should turn the client on one side. Nothing should be inserted into the child’s mouth during a seizure as it can stimulate the gag reflex, which may result in aspiration. Midazolam may be administered after the seizure. Fractures may occur if the nurse attempts to hold the child still. Turning the client on one side allows drainage of secretions, which prevents aspiration.
An LVN/LPN is tasked by the registered nurse to care for a 50-year-old client. The RN informed the LVN/LPN that an internal radiation implant is placed in the client’s cervix. Which of the following interventions would the nurse not reinforce?
The nurse keeps all bed linens in the client’s room until the implant is removed.
The nurse informs the client that she can see her 12 year old daughter no more than 30 minutes each day.
The nurse places a lead-lined container with a pair of long handled forceps in the client’s room.
Suggest that nursing assignments should be rotated daily.
Answer: B – A client with an internal implant in place in the cervix is not allowed to receive visitors who are below the age of 18 until the implant is removed. The client may also not see visitors who are pregnant. A client with an internal radiation implant is radioactive, thus a number of safety measures are necessary. The other options are correct.
An elderly client was admitted to the facility after complaining of weakness in the right arm and leg. The LVN/LPN determines that the client under her care is at risk of falls. Which of the following interventions would is the least appropriate?
Respond signal lights as soon as possible.
Place a bedside commode device adjacent to the side of the client’s bed.
Suggest that the client stay in a room near the nurse’s station.
Raise the side rails at night.
Answer: D – Raising the side rails at night is the least appropriate. This option may only be considered if the nursing staff has exhausted all their efforts to keep the client safe from falls. Responding to signal lights as soon as possible conveys to the client that help will be given, whenever it is needed. The client does not have to walk longer distances to use the bathroom with a bedside commode adjacent to bed. Having the client stay in a room near the nurse’s station will make it easier for the nurse to see the client when help is needed.
An LVN/LPN is tasked by the registered nurse to monitor a male client who is admitted due to pneumonia. A thoracentesis was performed 3 hours ago and the initial assessment has been performed by the RN after the procedure. Which of the following assessment findings noted by the LVN/LPN requires this finding should be reported immediately to the RN?
Uncontrollable coughing.
Crackles on auscultation.
Pain in the insertion site.
Bruising of punctured site.
Answer: A – If the client is coughing uncontrollably, the nurse should report it immediately to the RN. Uncontrollable coughing may indicate that the diaphragm may have been punctured during the thoracentesis. The other findings are expected after a thoracentesis.
An LVN/LPN in a pediatric unit is caring for an 8-year old child with a severe case of folate deficiency. The child’s laboratory test results indicated that the client has low counts of white blood cells, red blood cells and platelets. Which of the following clients is the most appropriate roommate for this child?
A child with intermittent low-grade fever.
A child with respiratory syncytial virus.
A child with vomiting and diarrhea.
A child with digoxin toxicity.
Answer: D – A child with pancytopenia may be roomed with a child diagnosed with digoxin toxicity. Pancytopenia, as manifested by low counts of white blood cells, red blood cells and platelets, should be is at great risk of infections. A child with digoxin toxicity is the least client to transmit any infectious disease to the client.
An LVN/LPN is assigned to care for a 29-year-old male client with circumferential third-degree burns in the right upper thigh. The client is in the resuscitative phase. Which of the following actions by the nurse is the most appropriate?