LPN LPN
LPN Fundamentals of Nursing
1. When assessing a client with chronic pain, which of the following is the most reliable indicator of the client's pain?
- A. The client's vital signs.
- B. The client's self-report of pain.
- C. The client's body language.
- D. The client's medical history.
Correct answer: B
Rationale: The client's self-report of pain is the most reliable indicator of pain. Pain is a subjective experience, and the client's self-report provides direct insight into their perception of pain intensity, quality, and impact on daily life. Vital signs, body language, and medical history can offer additional information but may not accurately reflect the client's actual pain experience. Therefore, relying on the client's self-report ensures a more accurate assessment of their pain and helps in tailoring appropriate interventions and treatment plans.
2. What action should the nurse take to prevent aspiration in a client receiving enteral nutrition?
- A. Flush the feeding tube with water before and after feedings.
- B. Elevate the head of the bed to 30-45 degrees during feedings.
- C. Administer the feeding slowly.
- D. Check the client's weight daily.
Correct answer: B
Rationale: Elevating the head of the bed to 30-45 degrees during feedings is essential to prevent aspiration in clients receiving enteral nutrition. This positioning helps decrease the risk of regurgitation and aspiration by supporting proper digestion and aiding food passage through the gastrointestinal tract. Elevating the head of the bed is a standard precautionary measure recommended to reduce the chances of aspiration and should be consistently implemented during feedings to ensure client safety and optimal enteral nutrition delivery.
3. During discharge instructions, a client with a new prescription for a metered-dose inhaler (MDI) states, 'I will shake the inhaler before each use.' Which of the following client statements indicates an understanding of the teaching?
- A. I will shake the inhaler before each use.
- B. I will use the inhaler immediately after meals.
- C. I will inhale the medication quickly.
- D. I will clean the mouthpiece with alcohol.
Correct answer: A
Rationale: The correct answer is A because shaking the inhaler before each use ensures that the medication is properly mixed, which is essential for effective administration. This action helps to disperse the medication evenly, enhancing its efficacy when inhaled. Proper mixing through shaking prevents inconsistent dosing and ensures that the client receives the correct amount of medication with each use.
4. A healthcare professional is preparing to administer an IM injection to a client. Which of the following techniques should the healthcare professional use to reduce discomfort?
- A. Use a 25-gauge needle.
- B. Administer the injection slowly.
- C. Massage the site after the injection.
- D. Apply ice to the injection site before administration.
Correct answer: B
Rationale: Administering the injection slowly is the recommended technique to reduce discomfort associated with IM injections. This approach allows the medication to disperse more gradually into the muscle, minimizing the sensation of pressure or pain during administration. Administering the injection slowly can also help prevent tissue damage and reduce the likelihood of injection site reactions.
5. What action should be taken to prevent respiratory complications in a client who is postoperative?
- A. Encourage the use of an incentive spirometer.
- B. Restrict fluid intake.
- C. Place the client in a supine position.
- D. Administer a cough suppressant.
Correct answer: A
Rationale: Encouraging the use of an incentive spirometer is crucial in preventing respiratory complications postoperatively. The incentive spirometer helps the client perform deep breathing exercises, which can prevent atelectasis (lung collapse) and promote lung expansion. This, in turn, reduces the risk of respiratory complications such as pneumonia. Restricting fluid intake, placing the client in a supine position, and administering a cough suppressant are not appropriate actions for preventing respiratory complications in a postoperative client.
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