the lpn is preparing to ambulate a client post total knee replacement which of the following actions should the nurse perform prior to ambulating the

NCLEX-PN

NCLEX PN 2023 Quizlet

1. The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?

A. Assist the client to a sitting position at the edge of the bed
B. Have the client march in place for 30 seconds
C. Have the client raise his arms above his head
D. Ask the client the last time he fell

Correct answer: A

Rationale: The correct action to perform before ambulating a client post total knee replacement is to assist the client to a sitting position at the edge of the bed. This step is crucial to prevent orthostatic hypotension and ensure the client is ready to stand and walk safely. Having the client march in place or raise his arms above his head are not necessary preparations for ambulation. While knowing about the client's fall history is important for safety reasons, it is not the priority action immediately before ambulating the client.

2. Which task would be appropriate for the LPN to perform?

A. Changing a colostomy bag.
B. Hanging a new bag of TPN.
C. Drawing a peak antibiotic blood level from a central line.
D. Administering IV pain medication to a two-day post-op client.

Correct answer: A

Rationale: The correct answer is changing a colostomy bag. This task falls within the LPN's scope of practice. LPNs are trained to provide basic nursing care, including assisting with activities of daily living and certain medical procedures like changing ostomy bags. Hanging a new bag of TPN and drawing a peak antibiotic blood level from a central line are tasks that require a higher level of training and are typically performed by RNs due to their complexity and potential risks. Administering IV pain medication to a two-day post-op client is usually the responsibility of an RN as it involves close monitoring, assessment of the client's condition, and the administration of potent medications that require a higher level of clinical judgment and expertise.

3. Which client should be seen first by the Emergency Department nurse?

A. A six-year-old with a femur fracture.
B. A two-year-old with a fever of 102 degrees F.
C. A three-year-old with wheezes in the right lower lobe.
D. A two-year-old whose gastrostomy tube came out.

Correct answer: C

Rationale: The priority in the emergency department is to assess and manage clients based on the severity of their condition. In this scenario, the three-year-old with wheezes in the right lower lobe should be seen first because respiratory distress takes precedence over other conditions. Wheezing indicates potential airway compromise, which requires immediate attention to ensure adequate oxygenation. The other options are important but do not pose an immediate threat to the client's airway and breathing. A femur fracture, fever, or a dislodged gastrostomy tube can be addressed after ensuring the child with respiratory distress is stable.

4. When teaching a client about anti-retroviral therapy for human immunodeficiency virus (HIV), the PN should emphasize:

A. When started, therapy must not be interrupted to prevent viral resistance.
B. When started, therapy must not be interrupted to prevent opportunistic infection.
C. Therapy should not be interrupted for one day each month to prevent toxicity.
D. Therapy should not be interrupted for one week every three months to prevent toxicity.

Correct answer: A

Rationale: When teaching a client about anti-retroviral therapy for HIV, it is crucial to emphasize that therapy must not be interrupted to prevent viral resistance. HIV mutates rapidly, and any interruption can lead to the emergence of resistant strains, compromising treatment effectiveness. Choice B is incorrect because keeping the virus in check with anti-retrovirals helps the client's immune system fight off opportunistic infections. Choices C and D are incorrect because therapy should not be interrupted for any reason. If toxicity occurs, the healthcare provider may adjust the treatment regimen by prescribing alternative anti-retroviral drugs.

5. High uric acid levels can develop in clients who are receiving chemotherapy. This can be caused by:

A. the inability of the kidneys to excrete the drug metabolites.
B. rapid cell catabolism.
C. toxic effects of the prophylactic antibiotics that are given concurrently.
D. the altered blood pH from the acidic nature of the drugs.

Correct answer: B

Rationale: The correct answer is 'rapid cell catabolism.' During chemotherapy, rapid cell destruction occurs, leading to an increase in uric acid levels as a byproduct of cell breakdown. High uric acid levels are primarily a result of the rapid breakdown of cells during chemotherapy, not due to the kidneys' inability to excrete drug metabolites (Choice A). The prophylactic antibiotics given concurrently do not directly cause high uric acid levels (Choice C). The altered blood pH from the acidic nature of the drugs (Choice D) is not a direct cause of elevated uric acid levels; the main mechanism is the rapid cell catabolism that occurs during chemotherapy.