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Two hours after the insertion of a Salem sump nasogastric tube, the client vomits a moderate amount of yellow-green fluid. What is the MOST appropriate action for the LPN/LVN to take?
- Inject 30 mL air and auscultate the left upper quadrant.
- Instill 20 mL carbonated beverage into the drainage tube.
- Inform the clinician of the vomiting.
- Irrigate the nasogastric tube with 20 mL normal saline.
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The LPN/LVN cares for a client after a motor vehicle accident. The LPN/LVN observes that the client is restless and anxious and has tremors of the hands. The family reports that the client has consumed 4 to 6 beers a day for 8 years. What is the PRIORITY action for the LPN/LVN to take?
- Reorient the client to the environment frequently.
- Place the client in a cool, darkened room.
- Assist the client to drink more isotonic fluids.
- Administer 100 mg thiamine IM.
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The LPN/LVN prepares to administer 300 mg isoniazid. What is a PRIORITY laboratory value to monitor prior to administration of the medication?
- Creatine kinase (CK)
- Aspartate aminotransferase (AST)
- Serum potassium
- Serum B12 levels
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The LPN/LVN reinforces instructions for a client taking clopidogrel 75 mg daily. Which statement by the client indicates understanding of the reinforced instructions?
- “It will be necessary for me to have frequent blood tests done now.”
- “I will need to discontinue the garlic tablets I take to control cholesterol.”
- “I can continue to take several ibuprofen a day for my low back pain.”
- “I will need to take a daily multivitamin tablet regularly now.”
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The LPN/LVN cares for the child whose parent reports abdominal cramps and diarrhea following the child’s ingestion of milk. Which of the following test results would rule out a diagnosis of lactose intolerance?
- Serum glucose level 20 mg/dL greater than the fasting glucose level
- Serum glucose level 20 mg/dL less than the fasting glucose level
- Fasting glucose level equal to the serum glucose level
- Fasting glucose level 10 mg/dL greater than the serum glucose level
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The LPN/LVN is preparing a primigravid woman to see her clinician. Laboratory test results are available, including a fasting blood sugar. Which result would indicate that gestational diabetes is likely?
- Serum glucose level of 40 mg/dL
- Serum glucose level of 100 mg/dL
- Serum glucose level of 140 mg/dL
- Serum glucose level of 180 mg/dL
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The physician has ordered diphenylhydantoin q.i.d. for the client. Prior to administering the second dose, the LPN/LVN observes that the client appears lethargic and has nystagmus and slurred speech. In addition to notifying the supervising RN, the LPN/LVN should do which of the following?
- Administer the diphenylhydantoin to prevent an oncoming seizure.
- Administer the diphenylhydantoin to prevent probable cardiac arrhythmia.
- Withhold the diphenylhydantoin due to signs of an allergic reaction.
- Withhold the diphenylhydantoin due to signs of toxicity.
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The LPN/LVN reviews medication information with a female client who has been prescribed sertraline daily. Which of the following statements by the client indicates a need for further instruction?
- “I will continue to take my birth control pills.”
- “If these pills don’t work in 2 weeks, I will stop taking them.”
- “I will take my pill first thing in the morning.”
- “I will skip a missed dose if it is almost time for my next one.”
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Within 5 minutes of beginning a blood transfusion, the client reports feeling very hot and sweaty, and the LPN/LVN observes that the client appears flushed. Which of the following actions should the nurse take FIRST?
- Notify the client’s physician.
- Stop the transfusion.
- Increase the saline drip rate.
- Take the client’s vital signs.
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The client comes to the urgent care clinic reporting “I’ve just stepped on a rusty nail at a construction site.” The LPN/LVN notes a deep puncture wound on the sole of the right foot. What order would the nurse expect to receive from the physician for this client?
- Complete blood count
- Urinalysis
- Tetanus vaccine
- Lumbar puncture