LPN LPN
LPN Fundamentals of Nursing
1. A healthcare professional is assessing a client who has deep-vein thrombosis (DVT). Which of the following findings should the professional expect?
- A. Swelling of the affected limb.
- B. Diminished peripheral pulses.
- C. Coolness of the affected limb.
- D. Redness and warmth of the affected limb.
Correct answer: D
Rationale: Redness and warmth of the affected limb are classic signs of deep-vein thrombosis (DVT) due to inflammation and increased blood flow. These symptoms occur as a result of the blood clot obstructing normal blood flow and causing localized inflammation in the affected limb. Swelling of the affected limb, diminished peripheral pulses, and coolness are not typically associated with DVT. Swelling can be present but is often accompanied by the characteristic redness and warmth. Diminished pulses and coolness are more indicative of arterial insufficiency rather than venous thrombosis.
2. When planning care for a client with a pressure ulcer, which intervention should the nurse include in the plan?
- A. Massage the reddened area.
- B. Apply a donut-shaped cushion.
- C. Reposition the client every 3 hours.
- D. Use a transparent film dressing.
Correct answer: D
Rationale: The correct intervention for a client with a pressure ulcer is to use a transparent film dressing. This dressing provides a protective barrier against external contaminants while allowing for wound inspection, promoting healing. Massaging the reddened area can cause further damage to the skin and should be avoided. Donut-shaped cushions can increase pressure on the ulcer site rather than alleviate it. Repositioning the client every 2 hours is a preventive measure for pressure ulcers, but once an ulcer has developed, using a transparent film dressing is a more appropriate intervention to facilitate healing and protect the wound site.
3. A client with a seizure disorder is under the care of a nurse. Which of the following precautions should the nurse include in the plan?
- A. Place a padded tongue depressor at the bedside.
- B. Keep the bed in the lowest position.
- C. Restrain the client during a seizure.
- D. Keep the lights dim in the client's room.
Correct answer: B
Rationale: Keeping the bed in the lowest position is crucial for ensuring the safety of the client during a seizure. Lowering the bed reduces the risk of injury if the client falls during a seizure episode. It is important not to restrain the client during a seizure as it can lead to further injury. Placing a padded tongue depressor at the bedside is not appropriate and can pose a risk of injury if used incorrectly. Keeping the lights dim in the client's room is not directly related to safety during a seizure and is not a standard precaution.
4. What action should the healthcare provider take for a patient with a chest tube?
- A. Strip the drainage tubing every 4 hours.
- B. Keep the drainage system below the level of the patient's chest.
- C. Clamp the chest tube when ambulating the patient.
- D. Ensure the water seal chamber is filled to the prescribed level.
Correct answer: D
Rationale: Ensuring the water seal chamber is filled to the prescribed level is essential for the chest tube's effective functioning. This maintains the integrity of the system, prevents air from entering the pleural space, and facilitates proper drainage. Stripping the drainage tubing, keeping the drainage system below the chest level, or clamping the chest tube during ambulation are not recommended practices and can lead to complications.
5. A healthcare provider is assessing a client who has anemia. Which of the following findings should the healthcare provider expect?
- A. Bradycardia.
- B. Pallor.
- C. Hypertension.
- D. Jaundice.
Correct answer: B
Rationale: Pallor is a common finding in clients with anemia due to decreased hemoglobin levels. Anemia leads to reduced oxygen-carrying capacity in the blood, resulting in pale skin and mucous membranes, which is known as pallor. Bradycardia, hypertension, and jaundice are typically not associated with anemia.
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