Answers and Explanations

Chapter Quiz

1. The answer is 4

   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?

   Strategy: Read the question and answer choices to identify the topic: possible obstruction of the nasogastric tube. As you can see, the answers are a mix of assessment and implementation actions.

   Recall the best standard of care according to nursing textbooks, and consider appropriate actions that may be taken before contacting the clinician. What action can be taken immediately with least risk of injury to the client?

   Category: Implementation/Physiological Integrity/ Reduction of Risk Potential

   1. Injection of air into the nasogastric tube with auscultation over the stomach is no longer an accepted standard of care to determine nasogastric tube position. Eliminate.
   2. This may be a “real world” answer. Carbonated beverage instillation is no longer an accepted standard of care to clear nasogastric tube obstruction. It has not been proven to be effective.
   3. If contacted, the clinician will want to know what actions have been taken. Does another answer choice describe actions within LPN/LVN scope of practice that can taken first? Keep for consideration.
   4. CORRECT: Irrigation with normal saline is an appropriate standard of care, is a safe action, and may clear the obstruction. Select this answer.
2. The answer is 1

   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?

   Strategy: First, consider the symptoms described in the question: They are early signs of alcohol withdrawal. What is the priority when caring for a client during early alcohol withdrawal? Safety of the client and safety of others.

   Next, determine which answer choice decreases the risk of injury to the client. When answering questions about safety, do not read into the answers or apply “real world” answers. Answer based on standards of care described in nursing textbooks.

   Category: Planning/Safe and Effective Envirnoment/Safety and Infection Control

   1. CORRECT: The client is at risk for hallucinations. Frequently giving accurate information about the environment will decrease the risk of injury.
   2. Some light is recommended to decrease the intensity of the hallucinations. Bright lights are not recommended, but lighting in the bathroom or soft lighting in the room allows the client to observe the actual environment.
   3. Dehydration is a risk for the client during alcohol withdrawal, but fluid administration does not decrease the risk of injury. Remember the topic of the question: safety.
   4. Thiamine is a vitamin (B1), and it may be administered to correct nutritional deficiencies and treat malnutrition. But it does not decrease the risk of injury.
3. The answer is 2

   The LPN/LVN prepares to administer 300 mg isoniazid. What is a PRIORITY laboratory value to monitor prior to administration of the medication?

   Strategy: The topic of the question is adverse effects of isoniazid (INH). Recall that isoniazid has the potential to cause liver injury. Which laboratory test indicates liver function?

   Category: Data Collection/Physiological Integrity/ Reduction of Risk Potential

   1. Creatine kinase (CK) levels rise when brain, muscle, or myocardial injury occurs. CK is not related to liver injury.
   2. CORRECT: Aspartate aminotransferase (AST) increases when liver injury is present. Clients taking isoniazid must be monitored for liver function.
   3. Serum potassium levels are not affected by liver injury.
   4. Serum B12 levels are not affected by liver function.
4. The answer is 2

   The LPN/LVN reinforces instructions for a client taking clopidogrel 75 mg daily. Which statement by the client indicates understanding of the reinforced instructions?

   Strategy: The topic is client understanding of instructions about clopidogrel (Plavix). You are looking for a correct statement. Eliminate incorrect answers.

   Category: Evaluation/Physiological Integrity/Pharmacological Therapies

   1. Clopidogrel is a medication that inhibits platelet function. Blood tests are not routinely done when a client takes clopidogrel.
   2. CORRECT: Is there a possible interaction between garlic and clopidogrel? Yes. Both substances inhibit platelet function and increase the risk of bleeding. This statement indicates understanding.
   3. Both ibuprofen and clopidogrel inhibit platelet function and increase the risk of bleeding. This statement does not indicate understanding of the drug interaction.
   4. While there is no contraindication to a multivitamin tablet, it is not specifically recommended when a client takes an antiplatelet medication.
5. The answer is 1

   The LPN/LVN cares for a 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?

   Strategy: “Rule out” means you need to identify normal laboratory values.

   Category: Evaluation/Physiological Integrity/Reduction of Risk Potential

   1. CORRECT: Lactose intolerance prevents the conversion of lactose into glucose. If the test shows a serum glucose level significantly greater (20 mg/dL) than the fasting glucose level, then lactose is being converted into glucose, ruling out a diagnosis of lactose intolerance.
   2. Without significant exercise or activity to decrease the amount of serum glucose, the fasting glucose level is never higher than the serum glucose level.
   3. No conversion of lactose to glucose is taking place, so results confirm a diagnosis of lactose intolerance.
   4. Without significant exercise or activity to decrease the amount of serum glucose, the fasting glucose level is never higher than the serum glucose level.
6. The answer is 4

   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?

   Strategy: Recall that the normal blood sugar in a pregnant woman can rise to 140 mg/dL. Then identify the abnormal (higher) value.

   Category: Evaluation/Physiological Integrity/Reduction of Risk Potential

   1. This result indicates severe hypoglycemia, and a cause for this condition should be investigated.
   2. This is a normal level for an adult woman.
   3. This is the upper limit of a normal glucose level for a pregnant woman.
   4. CORRECT: The serum glucose level needs to be above 140 mg/dL to be indicative of gestational diabetes.
7. The answer is 4

   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?

   Strategy: Identify the cause of the client’s signs and symptoms as possible diphenylhydantoin (Dilantin) toxicity.

   Category: Evaluation/Physiological Integrity/Pharmacological Therapies

   1. Lethargy, nystagmus, and slurred speech are not characteristic of a pre-seizure state.
   2. Although the diphenylhydantoin may have been prescribed to treat cardiac arrhythmia, the client’s symptoms are indicative of toxicity.
   3. The client’s symptoms are not characteristic of an allergic reaction.
   4. CORRECT: Lethargy, nystagmus, and slurred speech are signs of possible diphenylhydantoin toxicity. No more doses of this drug should be administered at present.
8. The answer is 2

   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?

   Strategy: Be careful! You are looking for incorrect information.

   Category: Evaluation/Physiological Integrity/Pharmacological Therapies

   1. All SSRIs, including sertraline (Zoloft), can cause birth defects if taken during pregnancy.
   2. CORRECT: It may take 4 weeks for sertraline to have a positive effect on the client’s symptoms; 2 weeks is too soon. Additionally, any decision to discontinue the medication must involve the prescribing clinician.
   3. While it is important to take the medication at the same time each day, it does not have to be in the morning.
   4. A missed dose should be omitted if it is almost time for the next dose.
9. The answer is 2

   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?

   Strategy: Priority question: Think about which action is most important for a client with a possible complication from treatment.

   Category: Planning/Physiological Integrity/Reduction of Risk Potential

   1. The physician can be notified after the correct actions have taken place.
   2. CORRECT: The transfusion must be discontinued immediately to avoid the risk of kidney damage or failure resulting from the possible destruction of red blood cells.
   3. The LPN/LVN needs to keep the line open with normal saline but should not use the saline attached to the Y-set tubing, because it may contain residual red blood cells incompatible with the client’s blood type.
   4. After the LPN/LVN stops the transfusion, the vital signs can be taken.
10. The answer is 3

    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?

    Strategy: Consider whether testing provides any needed information about the client’s status. Determine whether collecting data or implementing treatment is the priority.

    Category: Planning/Physiological Integrity/Physiological Adaptation

    1. A complete blood count is unnecessary because the client has not lost a significant amount of blood and has not reported further trauma.
    2. Urinalysis is unnecessary because the urinary tract is not the site of trauma.
    3. CORRECT: The deep puncture wound provides an ideal breeding ground for multiplying bacteria such as Clostridium tetani (common in soils, dust, and feces and on human skin). To prevent a potentially fatal bacterial infection of tetanus (“lockjaw”), the client would be given an injection of tetanus vaccine.
    4. A lumbar puncture withdraws fluid from the spinal column for analysis of problems with the brain or spine. It is not used to manage a puncture wound in the foot.