the lpn is caring for a client with an ng tube and the rn administers evening medications through the ng tube the client asks if he can lie down when

NCLEX-PN

Safe and Effective Care Environment Nclex PN Questions

1. The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?

A. You can lie down in 1 hour.
B. You can lie down in 30 minutes if your NG residual is below 50 mL.
C. You can lie down in about 30 minutes.
D. Yes, feel free to lie down.

Correct answer: A

Rationale: After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure proper absorption of the medications. Therefore, the most appropriate response is to advise the client to lie down in 1 hour. Choice B is incorrect because waiting only 30 minutes may not provide sufficient time for the medications to be fully absorbed, as the recommended time is 30 minutes. Choice C is misleading as it incorrectly suggests that lying down in about 30 minutes is acceptable, which could compromise medication effectiveness. Choice D is incorrect as it does not provide accurate information regarding the appropriate timing for lying down after NG tube medication administration, potentially leading to decreased medication absorption.

2. The nurse is preparing to administer the 9 am dose of IV antibiotics when she notes the IVAC cord is frayed with wiring visible. What action should be her priority for this client?

A. Notify maintenance to come and check the pump immediately.
B. Continue with the administration of the antibiotic and fill out an equipment maintenance request.
C. Immediately discontinue the use of this IVAC pump and obtain a replacement.
D. Tag the equipment for maintenance.

Correct answer: C

Rationale: The correct action is to immediately discontinue the use of the IVAC pump and obtain a replacement because the frayed cord poses a safety risk to the client. Continuing to use the pump with visible wiring could lead to electric shock or other serious harm to the client. Notifying maintenance to come and check the pump immediately (Choice A) may cause unnecessary delays in ensuring the client's safety. Continuing with the administration of the antibiotic and filling out an equipment maintenance request (Choice B) is unsafe as it ignores the immediate danger. Tagging the equipment for maintenance (Choice D) does not address the urgent need to protect the client from harm.

3. Why is monitoring Serum Vancomycin levels important?

A. to assess renal function
B. to determine therapeutic range
C. to measure trough levels
D. to evaluate antibiotic resistance

Correct answer: B

Rationale: Monitoring Serum Vancomycin levels is essential to determine the drug's therapeutic range, ensuring optimal effectiveness while avoiding toxicity. Peak levels indicate the drug's highest concentration, while trough levels represent the lowest concentration before the next dose. Assessing renal function is typically done using creatinine, BUN, or creatinine clearance tests, not Serum Vancomycin levels. Evaluating antibiotic resistance involves sensitivity testing, not monitoring Vancomycin levels. Therefore, the correct answer is to determine the therapeutic range.

4. What is the correct instruction to give a client undergoing mammography?

A. Do not use underarm deodorant.
B. Wear comfortable clothing.
C. Avoid caffeine prior to the procedure.
D. Bring a list of current medications.

Correct answer: A

Rationale: The correct instruction for a client undergoing mammography is not to use underarm deodorant. Underarm deodorant can cause confusing shadows on the X-ray film, affecting the accuracy of the mammogram. Choices B, C, and D are incorrect. While wearing comfortable clothing is advisable, it is not the primary instruction for mammography. Avoiding caffeine and bringing a list of current medications are not specific instructions related to mammography preparation and are therefore not the correct answers.

5. What is distraction therapy?

A. Focusing one's attention on stimuli other than pain.
B. Cognitive reappraisal.
C. The replacement of positive images of pain with other images.
D. The use of medication and meditation.

Correct answer: A

Rationale: Distraction therapy involves directing attention away from pain towards positive stimuli, which can help reduce the perception of pain. Choice A is the correct answer as it accurately defines distraction therapy. Cognitive reappraisal (Choice B) involves changing the way one thinks about a situation to alter its emotional impact, which is different from distraction therapy. Choice C is incorrect because distraction therapy does not involve replacing images of pain with other images, but rather focusing on something unrelated. Choice D is incorrect as distraction therapy does not necessarily involve medication or meditation, but rather the redirection of attention.