NCLEX Review- Kaplan

1. The LVN notes the client is allergic to an ordered medication. which is the correct action the by LVN?

Administer the medication as the physician ordered it

Administer the medication and closely observe the client

Call the pharmacist to verify potential allergic responses

Call the physician and report the medication allergy

Answer: D. The LVn must notify the MD regarding client's allergy so he or she can revise the medication order.

Explanation

Answer: D. The LVn must notify the MD regarding client's allergy so he or she can revise the medication order.

2. A cast is applied to a 9 month old girl for the treatment of talipes equinovarus. Which of the following instructions is most essential for the LVN to give to the child's mother regarding her care.

Offer appropriate toys for her age

Make frequent clinic visits for cast adjustment

Provide an analgesic as needed

Do circulatory checks of the casted extremity

Answer: D. A possible complication that can occur after a cast application is impaired circulation. All of these answer choices might be included in family teaching, but checking the child's circulation is the highest priority.

Explanation

Answer: D. A possible complication that can occur after a cast application is impaired circulation. All of these answer choices might be included in family teaching, but checking the child's circulation is the highest priority.

3. When caring for a client with anorexia nervosa, which of the following observations indicates to the LVN that the client's condition is improving?

The client eats all the food on her meal tray

The client asks friends to bring her special foods

The client weighs herself daily

The client's weight has increased

Answer: D. The client's weight is the most objective outcome measure in the evaluation of this client's problem

Explanation

Answer: D. The client's weight is the most objective outcome measure in the evaluation of this client's problem

4. The LVN obtains health history from a client admitted with acute glomerulonephritis that is associated with beta hemolytic streptococcus. The LVN expects which of the following to be significant in the health history?

The client has a sore throat two weeks earlier

There is a family history of glomerulonephritis

The client had a renal calculus two years earlier

The client had an accident involving renal trauma several years ago

Answer: A. Glomerulonephritis is an immunologic disorder that is caused by beta hemolytic streptococcus. It occurs 21 days after a respiratory or skin infection.

Explanation

Answer: A. Glomerulonephritis is an immunologic disorder that is caused by beta hemolytic streptococcus. It occurs 21 days after a respiratory or skin infection.

5. The LVN is caring for a 56 year old man receiving Haldol 2 mg PO BID. The LVN assists the patient to choose which of the following menus?

3 oz roast beef, baked potato, salad with dressing, dill pickle, baked apple pie, and milk

2 oz baked chicken, green beans, steamed rice, 1 slice of bread, banana and milk

Cheeseburger on a bun, french fries with catsup, chocolate chip cookie, apple and milk

3 oz baked fish, 1 slice of bread, broccolli, ice cream and pineapple drink taken 1/2-1 hour after the meal

Many students panic when they read this question because they can't immediately recall any diet restriction required by a pt taking Haldol. What type of diet do you chose for a pt receiving Haldol? Haldol is an antipsychotic medication used to treat psychotic disorders. There are NO diet restriction for clients taking Haldol. since there are no diet restrictions, you must problem-solve to determine what this question is REALLY asking. Based on the answer choices, it is obviously a diet question. What kind of diet should you choose for this pt? Since you have been given no information, there is only one type of diet that can be considered: a regular balanced diet.

Answer: B

A) Choice answer A is a balanced diet. But dill pickles are high in sodium.

B)This answer choice is a good answer because it contains foods from each of the food groups
C)This answer choice is not a balanced diet.This diet is high in fat and does not contain all of the food groups.
D)This choice isnt that bad but why would the intake of fluids be delayed?This sound like a menu to prevent dumping syndrome.

Explanation

Many students panic when they read this question because they can't immediately recall any diet restriction required by a pt taking Haldol. What type of diet do you chose for a pt receiving Haldol? Haldol is an antipsychotic medication used to treat psychotic disorders. There are NO diet restriction for clients taking Haldol. since there are no diet restrictions, you must problem-solve to determine what this question is REALLY asking. Based on the answer choices, it is obviously a diet question. What kind of diet should you choose for this pt? Since you have been given no information, there is only one type of diet that can be considered: a regular balanced diet.

Answer: B

A) Choice answer A is a balanced diet. But dill pickles are high in sodium.

B)This answer choice is a good answer because it contains foods from each of the food groups
C)This answer choice is not a balanced diet.This diet is high in fat and does not contain all of the food groups.
D)This choice isnt that bad but why would the intake of fluids be delayed?This sound like a menu to prevent dumping syndrome.

6. The LVN in the outpatient clinic notes that the blood pressure for an 88 year old client is 190/100. The LVN should take which of the following actions?

Report the blood pressure reading to the RN

Wait 20 minutes and retake the blood pressure

Use a different cuff and retake the blood pressure

Position the client supine with feet elevated

Answer: A. The LVN is responsible for data collection and should report findings that are abnormal to the supervising RN. Immediate actions should be taken, so B is incorrect. It is unnecessary to recheck the blood pressure using other equipment C or to position the client supine with feet elevated D.

Explanation

Answer: A. The LVN is responsible for data collection and should report findings that are abnormal to the supervising RN. Immediate actions should be taken, so B is incorrect. It is unnecessary to recheck the blood pressure using other equipment C or to position the client supine with feet elevated D.

7. After receiving report from the RN, which of the following clients should the LVN see FIRST?

A 31 yr old woman refusing Carafate before breakfast

A 40 yr old man with left sided weakness asking for assistance to the commode

A 52 yr old woman complaining of chills who is scheduled for a cholycystectomy

A 65 yr old man w/ nasogastric tube who had a bowel resection yesterday

ANSWER: C. This is the least stable pt.

Explanation

ANSWER: C. This is the least stable pt.

8. A 50 yr old male client comes to the nurses' station and asks the LVN if he can go to the cafeteria to get something to eat. When told that his privileges do not include visiting the cafeteria, the pt becomes verbally abusive. Which of the following approaches by the LVn would be most effective?

Tell the client to lower his voice because he is disturbing the other clients.

Ask the client what he wants from the cafeteria and have it delivered to his room

Calmly but firmly escort the client back to his room

Assign a nursing assistant to accompany the client to the cafeteria

Answer: C. The nurse should not reinforce abusive behavior. Clients need consistent and clearly defined expectations and limits.

Explanation

Answer: C. The nurse should not reinforce abusive behavior. Clients need consistent and clearly defined expectations and limits.

9. The MD orders amoxicillin 150 mg PO in oral suspension every 8 hrs for a 3 year old boy. the LVN enters the pt's room to administer the medication and discovers that the boy does not have an identification bracelet. What should the LVN do?

Ask the parents at the child's bedside to state their child's name

Ask the child to say his first and last name

Have a coworker identify the child before giving the medication

Hold the medication until an identification bracelet can be obtained

Answer: A. This action will allow the nurse to correctly identify the child and enable the nurse to give the medication on time.

Explanation

Answer: A. This action will allow the nurse to correctly identify the child and enable the nurse to give the medication on time.

10. A 7 year old girl with type 1 insulin dependent diabetes mellitus has been home sick for several days and is brought to the emergency by her parents. If the child is experiencing ketoacidosis, the LVN would expect which of the following lab results?

Serum glucose 140 mg/dl

Serum creatinine 5.2 mg/dl

Blood pH 7.28

Hematocrit 38%

Answer: C. Normal blood pH is 7.35-7.45. This indicated diabetic ketoacidosis

Explanation

Answer: C. Normal blood pH is 7.35-7.45. This indicated diabetic ketoacidosis

11. The LVN delivers external cardiac compressions to a client while performing cardiopulmonary resuscitation (CPR). which of the following actions by the LVN is BEST?

Maintain a position close to the client's side with the nurse's knees apart

Maintain vertical pressure on the client's chest through the heel of the nurse's hand

Re-check the nurse's hand position after every 10 chest compressions

Check for a return of the client's pulse after every 8 breaths by the nurse

Answer: B. The nurse's elbows should be locked, arms straight, with shoulders directly over hands. Incorrect pressure or improperly placed could cause injury to the client.

Explanation

Answer: B. The nurse's elbows should be locked, arms straight, with shoulders directly over hands. Incorrect pressure or improperly placed could cause injury to the client.

12. A client is being treated in the burn unit for second and third degree burns over 45% of his body. The MD orders include the application of silver sulfadiazine (Silvadene cream). the best way for the LVN to apply this medication is to use a sterile

4 x 4 soaked in saline

Tongue depressor

Gloved hand

Cotton-tipped applicator

The correct answer is C. A sterile, gloved hand will cause the least amount of trauma to tissues and will decrease the chances of breaking blisters

Explanation

The correct answer is C. A sterile, gloved hand will cause the least amount of trauma to tissues and will decrease the chances of breaking blisters

13. The LVN would know that his/her assignment was appropriate of assigned to which of the following clients?

A 56 year old woman with emphysema scheduled to be discharged later today

A 41 year old woman in traction with a fractured femur

A 34 year old woman with low back pain scheduled for a myelogram in the afternoon

A newly diagnosed 43 year old woman with type 1 diabetes mellitus

The correct answer is B. This client is in stable condition and can be cared for by an LVN

Explanation

The correct answer is B. This client is in stable condition and can be cared for by an LVN

14. A man had a permanent pacemaker implanted one year ago. He returns to the outpatient clinic because he thinks the pacemaker battery is malfunctioning. It is MOST important for the LVN to assess for which of the following?

Abdominal pain, nausea and vomiting

Wheezing on exertion, cyanosis and orthopnea

Peripheral edema, shortness of breath and dizziness

Chest pain radiating to the right arm, headache and diaphoresis

Answer: C. These are symptoms of decreased cardiac output. These symptoms occur with pacemaker battery failure. Other symptoms include changes in pulse rate, irregular pulse and palpitations.

Explanation

Answer: C. These are symptoms of decreased cardiac output. These symptoms occur with pacemaker battery failure. Other symptoms include changes in pulse rate, irregular pulse and palpitations.

15. An adolescent is seen in the emergency room for a fracture of the left femur sustained in a sledding accident. The fracture is reduced and a cast is applied. The client is taught how to use crutches for ambulating without bearing weight on the left leg. The LVN would expect the client to learn which of the following crutch-walking gaits?

2-point gait

3-point gait

4-point gait

Swing-through gait

Answer: B

Step 1: "See" a person walking normally. First the right leg and left arm, and then the left left and right arm are extended
Step 2: Put crutches in your hands. Now walk. Each foot and each crutch is a point
Step 3: See a person or yourself with a full cast on the left leg, with the foot never touching the ground.

A) 2-point gait. this sounds like normal walking. eliminate this choice because the pt is non weight bearing
B)3-point gait.Both crutches and one foot are on the ground. this would be appropriate for a non weight bearing pt.
C)4-point gait.This ould require legs and crutches to touch the ground. However, in this question the pt is non weight bearing
D)Swing through gait. This gait is not as stable as the other gaits.

Explanation

Answer: B

Step 1: "See" a person walking normally. First the right leg and left arm, and then the left left and right arm are extended
Step 2: Put crutches in your hands. Now walk. Each foot and each crutch is a point
Step 3: See a person or yourself with a full cast on the left leg, with the foot never touching the ground.

A) 2-point gait. this sounds like normal walking. eliminate this choice because the pt is non weight bearing
B)3-point gait.Both crutches and one foot are on the ground. this would be appropriate for a non weight bearing pt.
C)4-point gait.This ould require legs and crutches to touch the ground. However, in this question the pt is non weight bearing
D)Swing through gait. This gait is not as stable as the other gaits.

16. A client is admitted to the medical/surgical unit complaining of nausea, vomiting and severe right upper quadrant pain. His temperature is 101.3 F and an abdominal X ray reveals an enlarged gall bladder. He is scheduled for surgery. Which of the following actions should the nurse take FIRST?

Assess the client's need for dietary teaching

Evaluate the client's fluid and electrolyte status

Examine the client's health history for allergies to antibiotics

Determine whether the client has signed consent for surgery

Answer: B. Hypokalemia and hypomagnesemia commonly occur after repeated vomiting.

Explanation

Answer: B. Hypokalemia and hypomagnesemia commonly occur after repeated vomiting.

17. Which of the following symptoms, if observed by the LVN during the first 24 hrs after a percutaneous liver biopsy, would indicate a complication from the procedure?

Anorexia, nausea and vomiting

Abdominal distention, and discomfort

Pulse 112, blood pressure 100/60, respirations 20

Pain at the biopsy site

answer: C

A)Anorexia, nausea and vomiting. Does this indicate that the pt is hemorrhaging? No, these are not sx of hemorrhage

B) Abdominal distention and discomfort. Does this indicate that the pt is hemorrhaging?Perhaps. But abdominal distention could indicate internal bleeding.

C)Pulse 112, blood pressure 100/60, respiration 20. does this indicate that the pt is hemorrhaging?Yes. an increased pulse, a decreased blood pressure and increased respirations indicate shock. Shock is a result of hemorrhage.

D)Pain at the biopsy site. Does this indicate the pt is hemorrhaging?No. Pain at the biopsy site is expected due to the procedure.

Explanation

answer: C

A)Anorexia, nausea and vomiting. Does this indicate that the pt is hemorrhaging? No, these are not sx of hemorrhage

B) Abdominal distention and discomfort. Does this indicate that the pt is hemorrhaging?Perhaps. But abdominal distention could indicate internal bleeding.

C)Pulse 112, blood pressure 100/60, respiration 20. does this indicate that the pt is hemorrhaging?Yes. an increased pulse, a decreased blood pressure and increased respirations indicate shock. Shock is a result of hemorrhage.

D)Pain at the biopsy site. Does this indicate the pt is hemorrhaging?No. Pain at the biopsy site is expected due to the procedure.