which of these clients should the lpnlvn see first

NCLEX-PN

NCLEX PN Test Bank

1. Which of these clients should the LPN/LVN see first?

A. a client with a newly placed NG tube who is complaining of pain around the face and a plugged nose
B. a post-op prostatectomy client who complains of bladder spasms and blood in his foley bag
C. a client in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm
D. a client newly diagnosed with Hepatitis A who reports stomach pain and itchy skin

Correct answer: a client in an arm cast who is 2 days post-op and reports feelings of numbness and tingling in her affected arm

Rationale: Numbness and tingling hours or days after a cast is applied may indicate compartment syndrome and should be reported to a medical provider right away. This is a potential emergency situation that requires immediate attention to prevent complications. The other options present expected or typical symptoms related to their diagnosis, which do not require immediate intervention. Complaints related to a newly placed NG tube such as pain around the face and a plugged nose may require assessment and intervention but are not as urgent as potential compartment syndrome. Bladder spasms and blood in the foley bag post-prostatectomy are common postoperative issues that can be addressed after the client in the arm cast with potential compartment syndrome is seen. Stomach pain and itchy skin in a client with Hepatitis A are common symptoms of the condition and do not indicate an emergency situation.

2. When a 17-year-old client arrives at the clinic suspecting a sexually transmitted infection, what information does the nurse provide concerning informed consent?

A. She will need to sign an informed consent form.
B. Her mother or father will need to be contacted for permission to treat her.
C. A consent form is not needed if the problem is a sexually transmitted infection.
D. Anyone over the age of 18 years may sign a consent form for her treatment.

Correct answer: She will need to sign an informed consent form.

Rationale: Informed consent is a person’s agreement to allow something, such as a treatment, to be performed. A consent form is required even if the problem is a sexually transmitted infection. If the client is a minor, the minor may sign the informed consent form in specific situations, including seeking treatment for a sexually transmitted infection. In this case, the 17-year-old client is seeking examination and treatment for a sexually transmitted infection, so she will need to sign the informed consent form. Contacting her parents for permission is not required in this situation. Choice C is incorrect because a consent form is necessary regardless of the medical issue. Choice D is incorrect because the individual's age is not the determining factor; rather, it is the nature of the medical service being sought that dictates the need for informed consent.

3. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?

A. “I will assist you in arranging to have a medicine woman present.”
B. “We do not allow medicine women in exam rooms.”
C. “That does not make any difference in the outcome.”
D. “It is old-fashioned to believe in that.”

Correct answer: “I will assist you in arranging to have a medicine woman present.”

Rationale: The correct response is to show cultural awareness and respect the client's request by offering assistance in arranging for the medicine woman to be present. This approach acknowledges the importance of cultural beliefs and practices in the client's care, fostering trust and cooperation. Choices B, C, and D are inappropriate as they dismiss or belittle the client's cultural beliefs, showing insensitivity and lack of respect, which can negatively impact the nurse-client relationship.

4. Which is the proper hand position for performing chest vibration?

A. cup the hands
B. use the side of the hands
C. flatten the hands
D. spread the fingers of both hands

Correct answer: C

Rationale: The correct hand position for performing chest vibration is to flatten the hands. By flattening the hands over the area of the body where chest percussion is applied, vibrations can be conducted effectively to the chest to help loosen secretions. Cupping the hands may dampen vibrations, using the side of the hands reduces the surface area in contact with the chest, and spreading the fingers can lead to uneven pressure distribution. Therefore, flattening the hands provides the necessary contact and surface area to perform chest vibration efficiently.

5. As part of the teaching plan for a client with type I diabetes mellitus, the nurse should include that carbohydrate needs might increase when:

A. an infection is present.
B. there is an emotional upset.
C. a large meal is eaten.
D. active exercise is performed.

Correct answer: active exercise is performed.

Rationale: During active exercise, insulin sensitivity increases, leading to lower blood glucose levels. To balance the effect of increased insulin sensitivity, additional carbohydrates might be needed. The other choices are incorrect because: A) an infection typically raises blood glucose levels rather than increasing the need for carbohydrates; B) emotional upset can impact blood glucose but does not directly affect carbohydrate needs; C) while a large meal can raise blood glucose levels, it does not necessarily mean an increase in carbohydrate needs.