The nurse is discussing discharge plans with a 30-year-old client who has sickle cell disease. Assessment findings include spleenomegaly. What information obtained in the discussion would cause the most concern? The client:
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Solution
Answer D is correct. A client with an enlarged spleen has an increased risk for rupture; therefore, heavy lifting would be contraindicated. Answers A, B, and C would not be a cause for a concern because of the enlarged spleen.
A tuberculin test has been administered to an elderly client in preparation for nursing home placement. Which of these skin reactions at the site of the test could indicate a positive result?
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Solution
Answer A is correct. The hardening or induration could indicate a positive test result. A reaction of 0–4mm is not significant. A larger-size induration could indicate exposure to tuberculosis. Answers B, C, and D without induration are nonsignificant, so they are incorrect.
A 22-year-old female is being discharged after an admission for bipolar disorder. Discharge medications include valproate (Depakote). Which statement by the client would cause the nurse concern because of the prescription?
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Solution
Answer A is correct. Depakote can cause neural tube defects in pregnant women, so the client should be on birth control or should not take this drug. A client’s career, exercise level, and diet will not affect the dose or prescription for this drug, so answers B, C, and D are incorrect.
For the drugs Tamiflu and Relenza to be the most effective in eliminating the influenza virus, they should be administered within which time period?
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Solution
Answer A is correct. The best effect of the medications occurs if given within 2–3 days of illness with the influenza virus. Answers B, C, and D are not within the allotted time period for the drugs to be effective in eliminating the influenza virus.
A client who has had thoracic surgery has been instructed in arm and shoulder exercises. The nurse recognizes which of the following as the primary reason for these exercises?
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Solution
Answer A is correct. The reasons for these exercises are to restore movement, prevent stiffening of the shoulder area, and improve the client’s muscle power. Answer B is not prevented by the exercises utilized. Although the answers in C and D might have a positive outcome from performing these exercises, they are not the primary reason the exercises are done.
The LPN/LVN is describing a 24 hour urine collection to a client. Which of the following explanations is most accurate?
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Solution
Answer D is correct. Proper procedure is to empty the bladder and save the urine at the end of the collection period. Clients should void and discard the urine at the beginning of the collection period so answer A is incorrect. Answer B is utilized when collecting a mid stream (clean catch) specimen so it is incorrect. The urine doesn’t have to be collected in a sterile container, therefore C is incorrect.
The LPN/LVN is caring for a client with Clostidium difficile (C difficile). Which of the following observations indicates to the nurse that the client’s condition is improving?
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Solution
Answer D is correct. Dehydration is associated with C difficile due to the diarrhea and temperature elevation. Moist mucous membranes would indicate adequate hydration showing an improved patient outcome. Answers A, B, and D are manifestations of the condition and do not indicate an improvement, so they are incorrect.
The nurse is providing discharge instructions for a client who requires oxygen therapy at home. The client asks the nurse, “Will Medicare and Medicaid services pay for the oxygen?” The nurse’s response is based on the fact that the client’s PO2 must have been less than what level on room air for the client to receive financial reimbursement?
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Solution
Answer C is correct. This PO2 level is required for the client to receive financial assistance from Medicare and Medicaid services. The answers in A, B, and D are either above or below the level of PO2 requirement for reimbursement by Medicare and Medicaid services, so they are incorrect.
Which of the following dysrhythmias is most likely to occur during suctioning?
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Solution
Answer A is correct. Excessive vagal stimulation causes bradycardia because of parasympathetic stimulation. Answers B, C, and D are not arrhythmias associated with suctioning, so they are incorrect.
A client is scheduled for surgical repair of an abdominal aortic aneurysm. Which assessment is most crucial during the preoperative period?
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Solution
Answer C is correct. It is most important to identify the pulses preoperatively to have a baseline for post-operative evaluation. Answers A, B, and D are not priorities for the client preoperatively