Answers and Explanations

Chapter Quiz

1. The Answer is 4

   Two hours after the insertion of a Salem sump nasogastric (NG) 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 NG 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 primary health care provider. What action can be taken immediately with least risk of injury to the client?

   Category: Implementation/Physiological Integrity/Reduction of Risk Potential

   1. Injecting air into the NG tube while auscultating over the stomach is no longer an accepted standard of care for verifying NG tube placement. Eliminate.
   2. This may be a “real world” answer. Instilling a carbonated beverage to clear an NG tube obstruction is no longer an accepted standard of care. It has not been proven effective.
   3. If contacted, the primary health care provider 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 is caring for a client after a motor vehicle accident. The LPN/LVN observes that the client is restless, anxious, and has tremors of the hands. The family reports that the client has consumed 4 to 6 beers a day for the past 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:  A client may experience hallucinations during alcohol withdrawal. Reorienting the client to the environment helps maintain client safety during hallucinations.
   2. Some light is recommended to decrease the intensity of the hallucinations. Bright lighting is not recommended, but soft lighting allows the client to observe the surroundings.
   3. Alcohol withdrawal places the client at risk for dehydration, 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 is preparing to administer isoniazid 300 mg PO. Which of the following is a priority laboratory value to monitor before administering 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.  B-type natriuretic peptide (BNP) is a hormone produced by the heart. Levels increase when heart failure develops or worsens. BNP is not related to liver injury.
   2. CORRECT: Aspartate aminotransferase (AST) increases in the presence of liver injury. Liver function must be monitor in clients taking isoniazid.
   3. Serum potassium levels are not affected by liver injury.
   4. Vitamin B12 levels are not affected by liver function.
4. The Answer is 2

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

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

   Category: Evaluation/Physiological Integrity/Pharmacological Therapies

   1. Clopidogrel inhibits platelet function, however, routine blood test are not needed.
   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 is caring for a child whose parent reports that the child experienced abdominal cramps and diarrhea after ingesting milk. Which of the following test results would rule out the diagnosis of lactose intolerance?

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

   Category: Evaluation/Physiological Integrity/Reduction of Risk Potential

   1. CORRECT: Lactose intolerance prevents the conversion of lactose into glucose. If test results show a random serum glucose level significantly greater (20 mg/dL [1.1 mol/L]) than the fasting serum glucose level, then lactose is being converted into glucose; this rules out the diagnosis of lactose intolerance.
   2. Without significant exercise or activity to decrease the random serum glucose level, the fasting serum glucose level is never higher than the random serum glucose level.
   3. Lactose is not converting into glucose, so the results confirm the diagnosis of lactose intolerance.
   4. Without significant exercise or activity to decrease the random serum glucose level , the fasting glucose level is never higher than the random serum glucose level.
6. The Answer is 4

   The LPN/LVN is preparing a primigravid client for a primary healthcare provider examination. Laboratory test results are available. Which fasting serum glucose level result would indicate that gestational diabetes is likely?

   Strategy: Recall that the normal serum blood glucose level in a pregnant client can rise to 140 mg/dL (7.7 mmol/L). Then identify the abnormal (higher) value.

   Category: Evaluation/Physiological Integrity/Reduction of Risk Potential

   1. Serum glucose level of 40 mg/dL (2.2 mmol/L) indicates severe hypoglycemia; a cause should be investigated.
   2. Serum glucose level of 100 mg/dL (5.5 mmol/L) is a normal level for an adult female client.
   3. Serum glucose level of 140 mg/dL (7.7 mmol/L) is the upper limit of a normal serum glucose level for a pregnant client.
   4. CORRECT: Serum glucose level of 180 mg/dL (9.9 mmol/L); serum glucose level needs to be above 140 mg/dL (7.7 mmol/L) to suggest gestational diabetes.
7. The Answer is 4

   The primary health care provider prescribed phenytoin 100 mg PO 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 do not indicate an impending seizure.
   2. Although the phenytoin has antiarrhythmic properties, the client's findings suggest phenytoin toxicity.
   3. Lethargy, nystagmus, and slurred speech are not characteristic of an allergic reaction.
   4. CORRECT: Lethargy, nystagmus, and slurred speech suggest phenytoin toxicity. The drug should be withheld.
8. The Answer is 2

   The LPN/LVN is reviewing 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. Sertraline can cause birth defects if taken during pregnancy; the client should continue contraceptives during therapy.
   2. CORRECT: Sertraline may take 4 weeks to have a positive effect on the client’s symptoms; the client should not stop taking the medication without consulting with the primary healthcare provider.
   3. It is important to take the medication at the same time each day, but it does not have to be taken in the morning.
   4. A missed dose of sertraline 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 hot and diaphoretic, 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 primary health care provider can be notified after the correct actions have taken place.
   2. CORRECT: The blood transfusion must be discontinued immediately to avoid the risk of kidney damage resulting from the possible red blood cell destruction.
   3. The LPN/LVN needs to keep the IV catheter patent with normal saline solution but should not use the normal saline solution attached to the Y-administration set tubing, because it may contain residual red blood cells that are incompatible with the client’s blood type.
   4. After stopping the transfusion, the LPN/LVN should obtain the client's vital signs.
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 observes a deep puncture wound on the sole of the right foot. What order would the nurse expect to receive from the primary health care provider 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 suffered significant blood loss.
    2. Wound culture is not necessary for a new wound.
    3. CORRECT: A deep puncture wound provides an ideal reservoir  for the growth of Clostridium tetani (common in soils, dust, and feces and on human skin). To prevent tetanus, a potentially fatal bacterial infection, the primary health care provider would order the tetanus vaccine.
    4. A primary health care provider uses lumbar puncture to withdraw spinal fluid from the spinal column for analysis. It is used to identify conditions of the brain or spine, not to manage a puncture wound in the foot.