) A male client has just undergone a laryngectomy and has a cuffed tracheostomy
tube in place. When initiating bolus tube feedings postoperatively, when should the
nurse inflate the cuff?
A.Immediately after feeding
...
) A male client has just undergone a laryngectomy and has a cuffed tracheostomy
tube in place. When initiating bolus tube feedings postoperatively, when should the
nurse inflate the cuff?
A.Immediately after feeding
B.Just prior to tube feeding
C.Continuous inflation is required
D.Inflation is not required
Correct Answer: B Just prior to tube feeding
2) A client on telemetry has a pattern of uncontrolled atrial fibrillation with a rapid
ventricular response. Based on this finding, the nurse anticipates assisting the
physician with which treatment?
A.Administer lidocaine,75 mg intravenous push.
B.Perform synchronized cardioversion.
C.Defibrillate the client as soon as possible.
D.Administer atropine, 0.4 mg intravenous push.
Correct Answer: B Perform synchronized cardioversion.
3) A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an
ulcer on the heel of the left foot that has not healed with wound care. The nurse
observes that the entire left foot is darker in color than the right foot. Which
additional symptom should the nurse expect to find?
A.Pedal pulses will be weak or absent in the left foot.
B.The client will state that the left foot is usually warm.
C.Flexion and extension of the left foot will be limited.
D.Capillary refill of the client's left toes will be brisk.
Correct Answer: A Pedal pulses will be weak or absent in the left foot.
4) A client with cirrhosis develops increasing pedal edema and ascites. Which
dietary modification is most important for the nurse to teach this client?
A.Avoid high-carbohydrate foods.
B.Decrease intake of fat-soluble vitamins.
C.Decrease caloric intake.
D.Restrict salt and fluid intake.
Correct Answer: D Restrict salt and fluid intake.
5) During report, the nurse learns that a client with tumor lysis syndrome is
receiving an IV infusion containing insulin. Which assessment should the nurse
complete first?
A.Review the client's history for diabetes mellitus.
B.Observe the extremity distal to the IV site.
C.Monitor the client's serum potassium and blood glucose levels.
D.Evaluate the client's oxygen saturation and breath sounds.
Correct Answer: C Monitor the client's serum potassium and blood glucose levels.
6) The LPN/LVN receives the client's next scheduled bag of TPN labeled with the
additive NPH insulin. Which action should the nurse implement?
A.Hang the solution at the current rate.
B.Refrigerate the solution until needed.
C.Prepare the solution with new tubing.
D.Return the solution to the pharmacy.
Correct Answer: D Return the solution to the pharmacy.
7) A resident in a long-term care facility is diagnosed with hepatitis B. Which
intervention should the nurse implement with the staff caring for this client?
A.Determine if all employees have had the hepatitis B vaccine series.
B.Explain that this type of hepatitis can be transmitted when feeding the client.
C.Assure the employees that they cannot contract hepatitis B when providing
direct care.
D.Tell the employees that wearing gloves and a gown are required when providing
care.
Correct Answer: A Determine if all employees have had the hepatitis B vaccine
series.
8) The LPN/LVN notes that the client's drainage has decreased from 50 to 5 mL/hr
12 hours after chest tube insertion for hemothorax. What is the best initial action
for the nurse to take?
A.Document this expected decrease in drainage.
B.Clamp the chest tube while assessing for air leaks.
C.Milk the tube to remove any excessive blood clot buildup.
D.Assess for kinks or dependent loops in the tubing.
Correct Answer: D Assess for kinks or dependent loops in the tubing.
9) The nurse notes that a client who is scheduled for surgery the next morning has
an elevated blood urea nitrogen (BUN) level. Which condition is most likely to
have contributed to this finding?
A.Myocardial infarction 2 months ago
B.Anorexia and vomiting for the past 2 days
C.Recently diagnosed type 2 diabetes mellitus
D.Skeletal traction for a right hip fracture
Correct Answer: B Anorexia and vomiting for the past 2 days
10) The nurse is reviewing routine medications taken by a client with chronic angle
closure glaucoma. Which medication prescription should the nurse question?
A.Antianginal with a therapeutic effect of vasodilation
B.Anticholinergic with a side effect of pupillary dilation
C.Antihistamine with a side effect of sedation
D.Corticosteroid with a side effect of hyperglycemia
Correct Answer:B Anticholinergic with a side effect of pupillary dilation
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