Answers and Explanations

Chapter Quiz

1. The Answer is 4

   The LPN/LVN is caring for a client several hours after application of a right lower extremity cast. The client reports, “My right toes feel funny.” What is the first action the LPN/LVN should take?

   Strategy: Read the question to identify the topic: possible decrease in circulation after cast application. The client is at risk for injury from compromised circulation.

   Next, read the answer choices. They are a mix of physiological and psychosocial, so apply Maslow: Rule out the psychosocial answers, and review the remaining options for sense and ABCs.

   Category: Data Collection/Physiological Integrity/Basic Care and Comfort

   1. What is the outcome of leg elevation? Circulation to the right leg, foot, and toes will decrease. Is this desired? No.
   2. This is not an appropriate first action. If an analgesic is administered, it may alter some of the observations that indicate circulatory compromise.
   3. Reassuring the client is psychosocial. Physical answers are the priority; eliminate.
   4. CORRECT: By comparing capillary refill of both right and left toes, the LPN/LVN observes circulation in the casted extremity. Prolonged capillary refill may indicate decreased blood flow to the right foot and toes.
2. The Answer is 4

   The LPN/LVN is assisting a client with ambulation  when the client begins to fall. What is the most appropriate action for the LPN/LVN to take?

   Strategy: Read the question and answers to identify the topic. All answer choices are implementations. The topic is client safety.

   Next, consider the outcome of each answer choice: Which best promotes client safety? Also consider appropriate body mechanics while assisting the client and protecting yourself from injury.

   Category: Implementation/Safe and Effective Care Environment/Safety and Infection Control

   1. Bending at the waist is an example of body mechanics that increase risk of injury to the LPN/LVN. Grasping the client under the arms does not provide the greatest stability while assisting the client.
   2. This action increases the risk of injury to the LPN/LVN. The LPN/LVN should place feet wide apart to increase safety.
   3. This action increases the risk of injury to the client. It is more important to assist the client to a safe position than to place the client on a chair or bed.
   4. CORRECT: The outcome of this action is desired. The positioning of the feet (wide) and pelvis (forward) ensures stability, and sliding the client down the leg decreases the risk of injury to the client.
3. The Answer is 3

   The LPN/LVN observes that a client’s radial pulse is now 56 beats per minute. It was 72 beats per minute 4 hours ago. What is the most important action for the LPN/LVN to take?

   Strategy: Think about what happens when a client’s heart rate decreases significantly: Cardiac output may decrease, leading to decreased perfusion of vital organs. Determine if data collection or implementation is more important.

   Category: Planning/Physiological Integrity/Physiological Adaptation

   1. Oxygen saturation levels indicate the amount of oxygen attached to the red blood cells. Are oxygen saturation levels affected by cardiac output? No. They are affected by altered respiratory function. Eliminate.
   2. Giving supplemental oxygen may be an appropriate action, but is it the priority action? More data is needed.
   3. CORRECT: If heart rate decreases, cardiac output and blood pressure decrease, decreasing blood flow to the brain and other vital organs and increasing the risk of organ damage. Select this answer.
   4. Observing bilateral pulse strength may be an appropriate action, but is it the most important? No. The priority is to gather data related to blood flow to vital organs. Eliminate.
4. The Answer is 4

   A client reports to the LPN/LVN, “I just started to feel short of breath.” The client has normal saline infusing at a rate of 75 mL/hour through a peripherally inserted central catheter (PICC) line. What is the first action the LPN/LVN should take?

   Strategy: The answer choices are a mix of physiological and psychosocial, so apply Maslow: Rule out the psychosocial answers, and review the remaining options for sense and ABCs.

   Category: Implementation/Physiological Integrity/Physiological Adaptation

   1. Obtaining the client's blood pressure may be an appropriate action, but is it the first action? The client reports shortness of breath, and immediate action is needed.
   2. Reassuring the client is a psychosocial answer; eliminate.
   3. What is the outcome of this answer? Observing the site of the PICC may show if infiltration or thrombophlebitis is present.
   4. CORRECT: What happens when the client is in the upright position? Chest expansion increases and respiratory status improves.
5. The Answer is 4

   The LPN/LVN at the urology clinic is obtaining a health history from an elderly male client who reports back pain during urination and difficulty starting and stopping the urine flow.  Which of the following goals is most important for the LPN/LVN to include in the client’s plan of care?

   Strategy: Think about the consequences of each goal in light of the client’s problem with his urinary system.

   Category: Data Collection/Safe and Effective Care Environment/Coordinated Care

   1. The client will not benefit from pain medication, because it will not address the cause of the discomfort during urination.
   2. Without laboratory test results, it is not known if the client has an infection, so antibiotic therapy is not warranted.
   3. Physical therapy is not indicated for urological conditions.
   4. CORRECT: The client will have a urinalysis and a serum prostate-specific antigen (PSA) testing to help diagnose the condition.
6. The Answer is 3

   The LPN/LVN is caring for the client whose vaginal delivery resulted in a stillborn infant. Which of the following actions by the nurse is the most important?

   Strategy: “Most important” indicates a priority. Maslow’s hierarchy of needs prioritizes the need for physiological survival.

   Category: Implementation/Safe and Effective Care Environment/Coordinated Care

   1. Although emotional support is important, it is psychosocial; physiological needs take precedence.
   2. There is no evidence of dehydration in this client.
   3. CORRECT: The nurse should check the client’s perineal pad frequently for excess bleeding. Circulation is the third of the ABCs.
   4. Checking for hemorrhaging, a physiological complication, is more important than educating about pain relief. 
7. The Answer is 2

   The LPN/LVN is observing the client who has just eaten lunch having an episode of projectile vomiting. Which of the following actions should the nurse take first?

   Strategy: “First action” indicates a priority. Determine if data collection or implementation is more important.

   Category: Planning/Safe and Effective Care Environment/Coordinated Care

   1. An emesis basin is inadequate to contain further projectile vomiting.
   2. CORRECT: Data collection about the client’s status is needed before action taking action.
   3. The primary health care provider will inquire about the client's vital signs.
   4. Recent food intake is unlikely to have caused projectile vomiting.
8. The Answer is 3

   A frail client is admitted to the hospital for dehydration. The client is incontinent of urine and stool. The LPN/LVN should give which of the following nursing diagnoses the highest priority?

   Strategy: Think about the basic needs of every client. Remember the ABCs.

   Category: Planning/Safe and Effective Care Environment/Coordinated Care

   1. Body image disturbance is a psychosocial concern. Physiological needs take priority.
   2. Self-esteem disturbance is also a psychosocial concern.
   3. CORRECT: The client’s dehydration impairs normal circulation.
   4. Although this physiological risk is present, circulation takes precedence over skin injury; remember the ABCs.
9. The Answer is 1

   The primary health care provider has ordered a condom catheter for a male client. Which of the following is the most important question the LPN/LVN should ask the client before carrying out this order?

   Strategy: Determine why you would ask each question.

   Category: Data Collection/Safe and Effective Care Environment/Coordinated Care

   1. CORRECT: A latex allergy would preclude the use of some condom catheters.
   2. Research has shown that condom catheters cause fewer urinary tract infections than indwelling urinary catheters.
   3. After the primary health care provider has ordered the condom catheter, the client’s voiding pattern is not an issue.
   4. Circumcision is not a contraindication to use of a condom catheter.
10. The Answer is 2

    The client is about to be discharged home with a portable oxygen delivery system. The LPN/LVN knows that which of the following education topics is most important for the client’s family?

    Strategy: “Most important” indicates a priority. Consider the outcome of each answer choice.

    Category: Implementation/Safe and Effective Care Environment/Coordinated Care

    1. Treatment education is important, but basic physical safety takes priority.
    2. CORRECT: Flame or any source of heat, such as a lit cigarette, candle, or space heater, could cause a fatal fire in the presence of an oxygen delivery system.
    3. The risk of fire must be taught before addressing any concern about relaxation.
    4. Education about basic physiological needs is important, but warning about the risk of a fatal fire takes priority.