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While providing care on a medical unit, which of the following patients should the LPN/LVN see first?
a.
A patient who has a temperature of 106°F (41.1°C)
b.
A patient who needs assistance to ambulate
c.
A patient who needs discharge teaching
d.
A patient who states, “No one cares about me”
ANS: A
According to Maslow, humans’ basic needs (physiological) have the highest priority, and these patients should be seen first. Life-threatening needs are ranked first, health-threatening needs are second, and health-promoting needs are last. The elevated temperature has the greatest urgency. B, C, and D are not as high a priority.
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During a class discussion, one nursing student states belief in the practice of restraining patients. Another student has presented information regarding the unrestrained environment. Both students understand each other’s points of view. This is an example of what component of critical thinking?
a.
Intellectual empathy
b.
Intellectual integrity
c.
Intellectual courage
d.
Intellectual sense of justice
- ANS: C
- Intellectual courage allows one to look at other points of view. A. Intellectual empathy allows one to consider another’s situation and feelings. B. Intellectual integrity is seeking the same level of proof for comparable items. D. Intellectual sense of justice is ensuring that one’s thinking is not biased by analyzing motives.
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____ 3. Which of these human needs is being met when staff members have a potluck dinner with a congratulatory cake for a newly licensed practical nurse?
a.
Physiological
b.
Safety and security
c.
Self-esteem
d.
Self-actualization
ANS: C
Recognizing a person’s accomplishments will enhance his or her self-esteem. A, B, and D fall into other categories of human needs.
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The nurse is caring for a patient with a newly fractured femur who reports a pain level of 8/10. The nurse checks the medication record and finds that the analgesic medication is not due for another 50 minutes. Which of these actions would be appropriate for the nurse to take next?
a.
Tell the patient it is too early for pain medication.
b.
Notify the registered nurse or physician.
c.
Give the medication in 30 minutes.
d.
Reposition the patient.
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Which of these is an appropriate description of critical thinking?
a.
Directed thinking
b.
Indirect thinking
c.
Crisis thinking
d.
Criticizing thinking
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Which of these individuals would be most appropriate to include when planning care for a newly admitted patient and setting goals for the desired outcome?
a.
Patient’s family members
b.
Patient’s physician
c.
Nurse manager
d.
Patient
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While caring for a patient 4 hours after a surgical procedure, the LPN/LVN notes serosanguineous drainage on the dressing. Which of the following statements best documents this finding?
a.
“Normal drainage noted.”
b.
“Scant sersanguineous drainage seen on dressing.”
c.
“Moderate drainage recently noted.”
d.
“Pale pink drainage 2 cm by 1 cm noted on dressing.”
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The nurse is caring for a patient who is scheduled for surgery. Which data should the nurse collect to identify safety and security needs?
a.
Sexual activity patterns
b.
Anxiety about surgery
c.
Sleep patterns
d.
Meal patterns
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Which of these data is objective patient information?
a.
Patient is pleasant.
b.
“It has been a good day.”
c.
Patient’s appetite is poor.
d.
Urine output is 300 mL.
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Which of these nursing diagnoses would be the highest priority for the nurse to address in a postoperative patient?
a.
Deficient knowledge
b.
Impaired mobility
c.
Impaired skin integrity
d.
Acute pain
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A patient who has hypertension that is not well controlled with medication has been prescribed a new medication. The patient reports fatigue and lightheadedness after taking the first dose. The physician says not to worry about it and to continue giving the medication. The nurse is still concerned, however, and does some independent research on the drug on the Internet. This is an example of what type of critical thinking skill?
a.
Intellectual courage
b.
Intellectual perseverance
c.
Intellectual empathy
d.
Sense of justice
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Which is the best example of a measurable outcome for a patient with deficient fluid volume?
a.
Fluids will be at the bedside for the patient.
b.
Fluids the patient likes will be at the bedside.
c.
Patient’s intake will be 3,000 mL daily.
d.
Patient’s intake will be measured daily.
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The nurse is caring for a patient with a nursing diagnosis of fluid volume excess. Which of the following would the LPN/LVN use to best determine that care was effective?
a.
Discuss the patient’s care plan with the RN.
b.
Teach the patient to monitor fluid balance.
c.
Check the patient’s weight each day.
d.
Restrict the patient’s fluid intake.
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The LPN and LVN assist the RN in many phases of the nursing process. Which phase can the LPN or LVN carry out independently, once it has been delegated by the RN?
a.
Assessment
b.
Nursing diagnosis
c.
Planning care
d.
Implementation
e.
Evaluation
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The nurse is caring for a patient with a painful back injury that occurred 6 months ago. Which nursing diagnosis—using the Problem-Etiology-Symptoms (PES) system—is best?
a.
Acute pain related to patient pain rating of 6 as evidenced by muscle spasms and nerve compression
b.
Chronic pain related to muscle spasms as evidenced by patient pain rating of 8 and difficulty walking
c.
Acute pain related to inability to sit as evidenced by muscle spasms
d.
Pain as evidenced by herniated lumbar disk
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An LVN assisted an RN in revising the care plan for a patient who was not eating well. The RN added the intervention of sitting with the patient during meals. The LVN finds that the patient is still not eating today, even after staying with the patient for breakfast and lunch. What should the LVN do next?
a.
Develop a new plan of care.
b.
Revise the patient outcome to one that is achievable.
c.
Provide data to the RN to assist in evaluation of the plan.
d.
Collaborate on a new nursing diagnosis with the RN.
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A new shift is starting, and the LPN is given a list of assigned patients. Of the following patients, whom should the LPN see first?
a.
A patient reporting constipation and stomach cramps
b.
A 2-day postsurgical patient reporting pain at a level of 6
c.
A patient with pneumonia who is short of breath and anxious
d.
A patient scheduled for an MRI due to back pain
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For a patient who has all of the following nursing diagnoses, which should be given highest priority?
a.
Anxiety
b.
Constipation
c.
Deficient fluid volume
d.
Ineffective airway clearance
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The nurse planning patient care uses the systematic organizing framework of the nursing process. Which of these responses gives the nursing process steps in order?
a.
Data collection, intervention, nursing diagnosis, rationale, evaluation
b.
Nursing diagnosis, intervention, rationale, evaluation, planning
c.
Assessment, nursing diagnosis, planning, implementation, evaluation
d.
Data collection, evaluation, nursing diagnosis, implementation, rationale
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What is the term used in the nursing process for the patient’s problem?
a.
Patient data
b.
Nursing diagnosis
c.
Nursing intervention
d.
Outcome planning
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Which of the following provides measurable information to determine achievement of patient outcomes?
a.
Subjective terminology
b.
Open-ended time frames
c.
Objective observations
d.
P-E-S format
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Which of the following needs on Maslow’s hierarchy has the lowest priority?
a.
Physiological needs
b.
Self-actualization
c.
Self-esteem
d.
Safety and security
-
Which of the following needs on Maslow’s hierarchy is given highest priority?
a.
Physiological
b.
Self-actualization
c.
Self-esteem
d.
Safety and security
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____ 24. The nurse is in a restaurant and observes a person who appears to be in respiratory distress. The person’s family is becoming excited. The nurse goes to the table to help. Which of these actions should the nurse take first?
a.
Diagnose the problem.
b.
Collect data about the person’s condition.
c.
Gather data from the family.
d.
Assist the patient to lie down.
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Which of the following are official NANDA nursing diagnoses? (Select all that apply.)
a.
Diabetes
b.
Acute pain
c.
Impaired physical mobility
d.
Pancreatitis
e.
Activity intolerance
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A nurse is admitting a patient with high blood glucose levels, confusion, an unsteady gait, and dehydration. The patient has a family history of diabetes. Which of these are appropriate nursing diagnoses for the nursing care plan? (Select all that apply.)
a.
Hyperglycemia
b.
Diabetes
c.
Risk for falls
d.
Dehydration
e.
Deficient fluid volume
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The nurse is providing care for a patient recovering from a hip replacement who has a history of respiratory disease. Place the following nursing diagnoses in order of priority (1–4).
_____ Risk for injury related to unsteady gait
_____ Knowledge deficit related to use of a walker
_____ Acute pain related to surgery
_____ Impaired gas exchange related to compromised respiratory system
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