5 Written Questions

1. (B) Erythrocyte sedimentation rate (ESR)
   Rationale: Erythrocyte sedimentation rate (ESR) is the best diagnostic indicator of rheumatoid arthritis. ESR is a nonspecific test that indicates the presence of an inflammatory disease when elevated. Rheumatoid arthritis is one of a number of disease processes that will elevate this serum level. Serum creatinine is used to evaluate kidney function. International normalized ratio (INR) tests the effectiveness of anticoagulation therapy, usually with the drug Warfarin (Coumadin). A fasting lipid panel measures the cholesterol and lipid levels and ratios that are present in the blood when the levels are not affected by recent food ingestion.
2. (C) Until the degree of leukemia involvement is determined in the child, it is best to keep the child away from other children as much as possible. The white blood cells of a client with leukemia are ineffective. This causes decreased immunity. Infection from another child or person could be detrimental to a child with this condition. A semiprivate room is not recommended at this time. Unless the child is in critical condition, assignment to an intensive care bed is not necessary.
3. dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
4. Clients remain alert and oriented
   P- Pupils
   E- Equal
   R- Reactive
   L- Light
   M- Moving
   A- All
   E- Extremities to commands
   Compare to last nuero check is the client easy to arouse
   Squeeze your hands
   Left side of brain controls right body
   Right side of brain controls left body
   If CVA on right left affected
   If Hemi on right right is affected
   Strong side allways leads ex hemi on left side put chair on right side
   CVA on left put chair on left side
5. 1. Using restraints to immobilize the limbs
   Rationale: Using limb restraints will not alleviate spasticity and could harm the client. Their use should be avoided. Use of muscle relaxants may be helpful if the spasms cause discomfort to the client or pose a risk to the client's safety. Removing potentially harmful objects is a good basic safety measure. Range-of-motion exercises are beneficial in stretching muscles, which may diminish spasticity.

5 Matching Questions

1. Equal pupillary constriction in response to light
2. Mrs. Wilkins is in her second post-op day with a right-above-the-knee amputation. She asks the nurse why her stump must be rewrapped every day with an elastic bandage. Which of the following is the most appropriate reason for this procedure?
   (A) "The bandage absorbs drainage and blood from the incision site."
   (B) "The bandage helps shape the stump and shrinks the stump size."
   (C) "The bandage prevents dehiscence of the incision caused by movement."
   (D) "The bandage helps increase circulation to the incision site."
3. The distance has been determined and marked on the tubing for inserting a nasogastric tube into a client's gastrointestinal tract. Using all answers provided, arrange the following answer choices into the order of steps that would be followed during insertion of a nasogastric tube:
   (A) Lubricate the tip of the NG tube
   (B) Wash hands and put on gloves
   (C) Ask the client to tilt the head forward
   (D) Check tube placement
   (E) Ask the client to hyperextend the neck
   (F) Have the client swallow sips of water while advancing the tube 5 to 10 centimeters with each swallow
4. A concerned mother brings her 3 year old son to the pediatric clinic after discovering a rash that started on his face and progressively spread down his entire body. The LPN/LVN describes the rash to the physician as pin point sized reddened marks. Which of the following do these symptoms indicate that the child is infected with?
   (A) Chicken pox
   (B) Mumps
   (C) Rubella
   (D) Whooping cough
5. Decrease in LOC

1. a (C) Rubella
   Rationale: Rubella (German measles) involves a pinpoint rash that spreads quickly starting on the face and traveling down the body. Chicken pox usually appears first on the trunk as well as the scalp. The rash is described as macular to papular in appearance, and the vesicles crust over. Mumps does not involve rash formation. Symptoms of mumps include fever, headache, malaise and swollen salivary glands. Whooping cough or pertussis does not involve rash formation. Symptoms include coryza (inflammation of nasal mucosa), sneezing, watery eyes, cough that develops a "whooping" sound, fever and vomiting.
2. b (B) "The bandage helps shape the stump and shrinks the stump size."
   Rationale: The site of a new amputation will develop a large amount of edema. Stump wrapping with an elastic bandage shrinks and shapes the stump for prosthesis construction. Therefore, answer (B) is correct. The prosthesis will not be sized and constructed until the stump is cone shaped and the size is no longer changing. Gauze bandages are used to absorb blood and drainage. Dehiscence is the separation of the edges or reopening of a closed incision. With appropriate suturing, normal movement should not cause dehiscence. Antiembolism stockings are used to aid circulation in uncompromised limbs.
3. c A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
4. d (B) Wash hands and put on gloves
   (A) Lubricate the tip of the NG tube
   (E) Ask the client to hyperextend the neck
   (C) Ask the client to tilt the head forward
   (F) Have the client swallow sips of water while advancing the tube 5 to 10 centimeters with each swallow
   (D) Check the tube placement
   Rationale: Prior to any procedure, the nurse should perform appropriate hand-washing procedures and put on gloves. A lubricant is applied prior to insertion to ease movement through the gastrointestinal tract. During initial insertion of the tube, the client should hyperextend the neck to reduce the curvature of the nasopharyngeal junction. Once the tube is past the nasopharyngeal junction, the client should tilt the head forward to prevent the tube from going into the larynx. Once in the esophagus, having the client take sips of water while advancing the tube will make the process more natural and prevent discomfort. Once the desired length of the tube is inserted, it is important to confirm that the tube is placed in the stomach and not in the lungs.
5. e You are the nurse assigned to perform an eye assessment on an 80-year-old client. Which of the following findings during the assessment is considered normal?

5 Multiple Choice Questions

1. 2. Submerging the NG tube in water to check for bubbling
   Rationale: The most potentially hazardous method for checking NG tube placement is to submerge the end of the tube in water to observe for bubbling. This could put the client at risk for aspiration if the client breathed in fluid while the tube was in the lungs. Each of the other methods described is acceptable. The best method of determining tube placement is to verify by x-ray.
   1. The nursing assistant runs out of a hospital room yelling that the patient fell to the floor. The LPV/LVN is rehearsing in her mind the order of nursing actions that should be performed when at the client's side. Arrange the following into the correct order of priority, with the highest priority action listed first:
      (A) Assess airway patency
      (B) Assess for injury
      (C) Move the client into bed
      (D) Check heart rate and blood pressure
      (E) Call the client's physician
   2. A nurse is assisting in the care of a client with a nasogastric (NG) tube. The nurse understands that which of the following would be the most potentially hazardous method for checking tube placement when giving care to the client?
      1. Measuring the pH of gastric aspirate
      2. Submerging the NG tube in water to check for bubbling
      3. Aspirating the NG tube with a 50 mL syringe for gastric contents
      4. Instilling 10 to 20 mL of air into the NG tube while auscultating over the stomach
   3. Mrs. Strobell is walking in the hallway with the nursing assistant. She experiences sudden onset of angina. Which of the following should be the first action taken by the LPN/LVN?
      (A) Call the physician immediately
      (B) Instruct Mrs. Strobell to relax and discontinue all muscle movement
      (C) Tell the nursing assistant to help Mrs. Strobell walk back to her bed slowly and lie down
      (D) Retrieve a wheelchair and an oxygen tank from the supply room and transport Mrs. Strobell back to her room
   4. Mrs. Wilkins, is a 60 year-old client with advanced diabetic neuropathy, is two days post-op from a right-above-the-knee
      amputation. During assessment, the LPN/LVN asks the client if she is experiencing any pain. Mrs. Wilkins replies. "I've been afraid to mention it. I know my right foot isn't there anymore, but I feel it aching." Which of the following is the most accurate explanation for this sensation?
      (A) "You may feel pain in the tissues near the incision site, which is known as referred pain."
      (B) "You may be experiencing a psychosomatic pain response as a result of the loss you are experiencing."
      (C) "You may be experiencing intractable pain, which can be controlled with the appropriate narcotics."
      (D) "You may be experiencing a sensation called 'phantom pain' from the site of the amputation."
2. 1. Position the client in the center of the sling
   Rationale: One person may operate a hydraulic lift. The client is positioned in the center of the sling, which is then attached to chains or straps that connect the sling to the lift. The client is raised from the bed into a sitting position. The lift raises the client off the mattress and lowers the client slowly once the sling is positioned over the chair.
   1. A nurse is preparing to assist a client from the bed to chair using a hydraulic lift. The nurse should do which of the following to move the client safely with this device?
      1. Position the client in the center of the sling
      2. Have three staff members available to assist
      3. Lower the client rapidly once positioned over the chair
      4. Have the client grasp the chains attaching the cling to the lift
   2. A nurse is assigned to care for a client with cervical cancer who has an internal radiation implant. Which of the following required items should the nurse ensure is kept in the client's room during this treatment?
      1. A lead shield
      2. A bedside commode
      3. A no. 16 Foley catheter
      4. Long-handled forceps and a lead container
   3. A nurse is assisting in the care of a client in labor who has a history of sickle cell anemia. Knowing that the client has a high risk for sickling crisis during labor, the nurse should give priority to implementing which safe nursing action to prevent a crisis from occurring?
      1. Maintain strict hand washing technique
      2. Give the client reassurance and encouragement
      3. Ensure that the client uses oxygen during labor
      4. Remind the client not to bear down for more than 3 seconds
   4. A nurse is preparing to suction a client's tracheostomy. To ideally promote deep breathing and coughing, in which position should the client be safely placed?
      1. Supine
      2. Lateral position
      3. High-Fowler's position
      4. Semi-Fowler's position
3. (C) Toes
   Rationale: Prone position involves the client lying with the anterior surface of the body compressed against the bed or lying area. The occiput, elbow and coccyx (also called the tailbone) are all pressure points that would be compromised if the client were to lay with the posterior surface against the bed or lying area. The toes would be compressed against the lying area with the client in the prone position. Therefore, the correct answer is (C).
   1. Which of the following are appropriate steps that are involved in irrigating a client's eye?
      (A) Have the client tilt his/her head toward the opposite eye
      (B) Wash hands and put on gloves
      (C) Irrigate with the solution until the eye is no longer reddened
      (D) Place the drops of solution into the center of the eye
      (E) Place the drops of solution into the inner corner of the eye
      (F) Offer a tissue to the client
   2. A nurse is implementing measures to prevent the spread of infection to other clients. The nurse understands that which of the following is the best way to prevent the spread of infection?
      1. Use proper hand washing techniques
      2. Use sterile technique with all procedures
      3. Never stop in the middle of performing a procedure
      4. Read the policy and procedure manual before performing treatments
   3. Which of the following is the most important information obtained from the client that presents to the physician's office with right calf tenderness?
      (A) High levels of work related stress
      (B) Use of oral contraceptives
      (C) Left femur fracture 18 months prior
      (D) Plays in a soccer league
   4. Which of the following pressure points is most likely to be at risk for developing a pressure wound while a client is in the prone position?
      (A) Occiput
      (B) Elbows
      (C) Toes
      (D) Coccyx
4. 3. Povidone-iodine
   Rationale: Before bone marrow aspiration, the needle insertion site is cleansed with an antiseptic solution such as povidone-iodine. This helps reduce the number of bacteria on the skin and decreases the risk of infection from the procedure. The other options are incorrect agents because they would not produce this effect.
   1. The physician has written an order for a client to be weighed daily. Which of the following instructions provided by the LPN/LVN to the nursing assistant is most important for obtaining accurate daily results?
      (A) The client should be weighed at the same time every day
      (B) The client should not have had anything to eat or drink for 30 minutes prior to weighing
      (C) The client should remove slippers from their feet prior to being weighed
      (D) If using an internal bed scale, it is important to subtract 5 lbs from the results to account for the linen on the bed
   2. A rehabilitation center nurse is planning the client assignments for the day. Which of the following clients should the nurse assign to the nursing assistant?
      1. A client who had a below-the-knee amputation
      2. A client on a 24-hour urine collection who is on strict bed rest
      3. A client scheduled for transfer to the hospital for an invasive diagnostic procedure
      4. A client scheduled to be transferred to the hospital for coronary artery bypass surgery
   3. A client is scheduled for a bone marrow aspiration. The nurse plans to bring which of the following skin cleansing agents to the bedside before this procedure for skin cleansing to prevent infection as a result of the procedure?
      1. Alcohol swabs
      2. Soap and water
      3. Povidone-iodine
      4. Hydrogen peroxide
   4. The LPN/LVN is preparing to give a subcutaneous injection of Procrit 5,000 units. Which of the following needles would be appropriate for this type of injection?
      (A) A 5/8 inch, 25 gauge needle
      (B) A 1 inch, 22 gauge needle
      (C) A 1.5 inch, 25 gauge needle
      (D) A 1.5 inch, 18 gauge needle
5. 1. Leaving the side rails down
   Rationale: Safe nursing actions intended to prevent injury to the client include keeping the side rails up, keeping the bed in low position, and providing a call bell that is within the client's reach. Responding promptly to the client's use of the call light minimizes the chance that the client will try to get up alone, which could result in a fall. Night-lights are built into the lighting systems of most facilities, and these bulbs should be routinely checked to ensure that they are working.
   1. A nurse is caring for an older client who had a hip pinned after being fractured. In planning nursing care, the nurse should avoid which of the following to minimize the chance for further injury?
      1. Leaving the side rails down
      2. Keeping the call bell in reach
      3. Answering the call bell promptly
      4. Ensuring that the night-light is working
   2. A nurse is observing a nursing assistant talking to a client who is hearing impaired. The nurse should intervene if which of the following were performed by the nursing assistant during communication with the client?
      1. The nursing assistant is speaking in a normal tone
      2. The nursing assistant is speaking clearly to the client
      3. The nursing assistant is facing the client when speaking
      4. The nursing assistant is speaking directly into the impaired ear
   3. A nurse is assigned to care for an older client who has been identified as a victim of physical abuse. In planning care for this client, the nurse's priority is focused toward:
      1. Removing the client from any immediate danger
      2. Adhering to the mandatory abuse reporting laws
      3. Encouraging the client to file charges against the abuser
      4. Referring the abusing family member for treatment
   4. A nurse is assigned to care for a client with Parkinson's disease who has recently begun taking L-dopa (levodopa). Which of the following is most important to check before ambulating the client?
      1. The client's history of falls
      2. Assistive devices used by the client
      3. The client's postural (orthostatic) vital signs
      4. The degree of intention tremors exhibited by the client

5 True/False Questions

1. Which of the following assessments is the most important when examining a client who is suspected to be experiencing a CVA (cerebral vascular accident):
   (A) Vital signs
   (B) Motor response
   (C) Integrity of the airway
   (D) Level of consciousness (LOC) → (D) Level of consciousness (LOC)
   Rationale: The first thing to assess in a client who displays signs and symptoms of a CVA (cerebral vascular accident) is level of consciousness (LOC). LOC most quickly and accurately indicates the level of brain function. This is also the first assessment in the ABCs of emergency response procedures. Airway integrity would be assessed after unconsciousness is confirmed. If the client is conscious, vital signs and motor response should then be assessed. Vital sign changes and motor response deficits give further information about the characteristics of the CVA.

   True        False

2. Accuracy of orders → sudden and general loss of muscle tone, particularly in the arms and legs, which often results in a fall.

   True        False

3. A licensed practical nurse (LPN) is reinforcing teaching done by the registered nurse (RN) with a client who has been diagnosed with endocarditis. The LPN explains that it is important for this client to use an electric razor rather than a straight razor for shaving because of which of the following?
   1. An electric razor can be sanitized more easily
   2. Straight razors harbors too many microorganisms
   3. The client is at a higher risk for infection from any nick or cut
   4. Any cuts or skin injury should be avoided while taking anticoagulants → 4. Any cuts or skin injury should be avoided while taking anticoagulants
   Rationale: Clients with endocarditis are at risk for developing thrombi along the walls of the heart, which could become emboli leading to stroke. For this reason, clients with endocarditis are treated with anticoagulant therapy to prevent thrombus formation. Clients on anticoagulants should implement measures to prevent injury and subsequent bleeding, The other options are incorrect because infection rather than bleeding is their primary focus.

   True        False

4. A nurse who is assisting in the care of suicidal clients in a psychiatric nursing unit should plan to implement special precautions at which of the following times of increased risk?
   1. Day shift
   2. Weekdays
   3. Shift change
   4. 8 am to 2 pm → 2. Identifying anxiety-producing events
   Rationale: Recognizing events that produce anxiety allows the client to prepare to cope with anxiety or avoid a specific stimulus. Counselors will not be available for all anxiety-producing events, and this option does not encourage the development of internal strengths. Ignoring feelings will not resolve anxiety. It is impossible to eliminate all anxiety from daily activities.

   True        False

5. A client with pulmonary tuberculosis (TB) asks the nurse how this disease was contracted. The nurse replies that TB is commonly spread by which of the following methods?
   1. Sneezing
   2. Shaking hands
   3. Contact with stool
   4. Contact with urine → 1. Sneezing
   Rationale: TB is spread by droplet nuclei, which become airborne when the infected client laughs, sings, sneezes, or coughs. An individual must inhale the droplet nuclei for the chain of infection to continue. Therefore it is not spread by shaking hands or contact with stool or urine.

   True        False